Procedure:
Left Heart Catheterization
Coronary angiography
LV angiography
Selective bilateral renal angiography
Right accessory renal artery angiography
PCI/Stent of right coronary artery
Indication/History:
This is a 58 y.o. AA male being evaluated for exertional angina pectoris. Dr. Grammes referred him for cardiac catheterization after he noted an abnormal OP nuclear stress test. Catheretization is performed for diagnosis and PCI for revascularization. His baseline serum creatine was abnormal at 1.6 mg/dl and as a result renal angiography was performed to rule out renal artery stenosis.
Assistant:
None
Approach:
RFA
Technique:
Seldinger
Anesthesia:
Conscious sedation with Versed and Fentanyl (see case log)
Diagnostic Catheters:
6fr JL-4
6fr JR-4
Guide Catheter(s):
1. 6 JR-4 with side holes
Guide Wire(s):
190 cm Universal
Balloon(s):
2.25 X 6 mm Sprinter
2.25 X 12 mm NC Sprinter
Stent(s):
2.25 X 22 mm Resolute Integrity drug-eluting
Adjunct Pharmacology:
Weight based Angiomax bolus and drip
Complictions:
None
Estimated blood loss:
<20cc
Contrast Used:
175 cc Visipaque
Description of procedure:
Following signed, informed consent, the patient was brought to the cardiac catheterization laboratory in the fasting state and was prepped and draped in the usual sterile fashion for the procedure. A time-out was done by the staff.The right groin was exposed and 10cc of 1% Lidocaine was infiltrated into skin and tissues overlying the right femoral triangle. Next, utilizing an 18 gauge Seldinger needle and a guide wire, a 6-french side-arm vascular sheath was placed into the right femoral artery. The guide wire was removed and the sheath was flushed with heparinized saline. Subsequently the 6-JL4 and 6-JR4 catheters were used to perform left heart catheterization, coronary and left ventricular angiography. Catheters were exchanged over a long J-tipped guide wire and all angiograms were performed in standard views and as per standard protocol.
Following the procedure, all catheters were withdrawn and the patient was prepared for PCI as described below.
Coronary Angiography:
LMCA: Large vessel that trifurcates into left anterior descending, intermediate and left circumflex coronary arteries. LMCA is angiographically normal.
LAD: Large type-3 artery that travels along the anterior interventricular groove and extends around the LV apex. The LAD has mild plaques but no high grade lesions. The third diagonal artery is small and contains a 50% ostial stenosis.
Intermediate: Moderately large vessel with a 30% ostial stenosis.
LCX: Moderate sized non-dominant artery. The LCX has an ostial 30% stenosis and a distal 80% discrete stenosis in an area where the vessel is 2.0 to 2.25 mm in diameter.
RCA: Moderate sized, dominant artery. The RCA contains a 25% tubular stenosis proximally, followed by a 50% proximal stenosis and then contains an 80% mid vessel stenosis. The PDA and PLV branches are angiographically normal.
Left Ventricle(30 degree RAO projection):
Normal cavity size. No wall motion abnormlaities. No significant mitral regurgitation. EF is 55%.
Selective Bilateral Renal Angiography AP projection):
A single left and a single right renal arteries were cannulated and injected. The left renal artery is angiographically normal. The right renal artery is angiographically normal. The right accessory renal artery was selectively cannulated and injected. It supplies the upper pole of the right kidney. that vessel is angiographically normal.
Percutaneous coronary Intervention:
Review of Cineangiograms: Following review of the cineangiograms I decided to perform a staged revascularization beginning with the RCA since his ischemia was demonstrated in the distribution of that vessel. The LCX vessel appeared relatively small and felt that it can be approached later if necessary. It will require a very small stent.
Description of Procedure:
Folowing the administration of adjunctive pharmacology, the guide catheter was carefully inserted into the RCA ostium without complictions. Next, the guide wire was advanced down the vessel, across the stenosis and was positioned at the distal end of the vessel without complictions.
Next, the Sprinter balloon was advanced over the guide wire and positioned across the stenosis. Following successful pre-dilatation, that balloon was removed. Next, the stent was inserted and carefully positioned across the stenosis. It and deployed and subsequently post-dilated to its final diameter.
Post Procedure Angiography:
RCA stenosis was reduced from 80% to 0% residual
TIMI flow:
Improved from grade 2 to grade 3
Sidebranch Compromise:
None
Conclusions:
Chronic angina pectoris
Three vessel coronary disease with 80% mid RCA stenosis and 80% distal LCX stenosis
Normal LV systolic function
Renal insufficiency
Angiographically norrnal renal arteries
Angiographically normal right accessory renal artery
Successful PCI and stent of right coronary artery
Recommendations:
Patient received Effient 60 mg load
Recommend 10 mg for 12 months along with ASA 81 mg daily
Aggressive risk factor modifications
Consider PCI of the LCX is still symptomatic and is ischemia can be demonstrated in its distribution
