jlb102780
Guru
Good Morning,
Was wanting some feed back on this case/second opinion please.
I've come up with:
37236
75625-26,59
I'm not fully seeing the Thoracic Aorta Arteriogram in this report.
PROCEDURE
1. Thoracic aorta arteriogram.
2. Implantation of 2 overlapping 7.0 mm Omnilink balloon-expandable bare
metal stents into the totally occluded proximal left subclavian area.
BRIEF HISTORY
The patient is a very pleasant 82-year-old female who has a rather extensive
past medical history. She has had coronary artery bypass surgery performed
in the past. She has been having severe pain in her left arm for several
years. These symptoms have worsened significantly. She had arterial Doppler
study performed and was found to have a totally occluded left subclavian
artery with reconstitution of the mid left subclavian artery. She also has
had recurrent falls and has history of sick sinus syndrome and has a
permanent pacemaker. After careful discussion of various options, she was
referred for an attempt at possible catheter-based intervention of the left
subclavian artery since she has had symptomatic left subclavian artery
occlusion.
CATHETERIZATION AND INTERVENTION REPORT
The patient was brought to the cardiac catheterization laboratory in very
stable condition. Both groins were carefully prepped and draped in the
routine sterile fashion. We turned our attention to the right coronary
artery. Using 1% Xylocaine, the right femoral artery was anesthetized.
Using a Cook needle, the right femoral artery was entered without difficulty,
and a 5 French sheath was inserted via the Seldinger technique. The sheath
was aspirated and flushed.
A 5-French pigtail catheter was then advanced into the patient's ascending
aorta. A couple of abdominal aortograms were performed in the LAO and AP
projections using digital subtraction angiography. We had some difficulty
visualizing the stump of the left subclavian artery. The left subclavian
artery was totally occluded just past the takeoff of the aorta. We
visualized the brachial cephalic and left common coronary artery very well.
The left subclavian artery appeared to fill faintly from collaterals.
I felt that our chances of successfully recannulizing the left subclavian
artery were not very high, but I felt it was worth the chance. The patient
was very symptomatic. We exchanged that for a long pinnacle destination
sheath, this sheath being 55 cm in length. The tip of this sheath was placed
into the patient's aortic arch and descending thoracic aorta. I then tried
to advanced several different guiding catheters and finally was able to
successfully manipulate the catheter into the ostium of the stump of the
totally occluded left subclavian artery. We were able to successfully
manipulate a 6 French right graft seeker coronary diagnostic catheter.
I then advanced an angioplasty wire and a 3.0 mm coronary balloon catheter.
Unfortunately, we were unable to get very far through the total occlusion
with balloon angioplasty wire. We ended up switching out for a 4-French 0.14
inch crossing seeker catheter. We utilized this in a 0.014 Choice standard
angioplasty exchange wire and were able to manipulate into the total
occlusion somewhat. I then switched out for a couple of different
angioplasty wires. We ended up switching out for a 0.014 Persuader
angioplasty wire and then a Confianza angioplasty exchange wire. We were
able to advance the crosser catheter into the patient's totally occluded left
subclavian artery. We then pulled the angioplasty wire and injected some
contrast. You could see a false lumen, but there was also a faint puff of
dye at what appeared to be the true lumen running off the patient's left
subclavian artery. After a great deal of difficulty, we were able to
manipulate a 0.014 Choice PT floppy exchange wire down this lumen up into the
patient's left subclavian artery. I easily advanced the crossing catheter
over the angioplasty wire. The angioplasty wire was removed. We then
injected dye through the crossing catheter and documented it clearing in the
patient's left subclavian artery at this point.
I then advanced a 0.014 inch Grand Slam angioplasty exchange wire. This was
a stiff wire that would help support a balloon catheter. The crossing
catheter was removed. We then predilated the left subclavian artery, first
with a 3.0 mm Maverick angioplasty coronary balloon catheter. We then
dilated the area with a 4.0 mm Armada peripheral balloon catheter, the
balloon being 40 mm in length. During this time, at the starting of the
interventional procedure, it should be noted that the patient was given 3000
units of IV heparin. We obtained an AZT that was noted to be 176 seconds
during the case period. She was given an additional 2000 units of IV
heparin. She also was given a couple of injections of intraarterial
nitroglycerine. We then continued to dilate the area to help size the
vessel. We dilated the area with a 6.0 mm Fox Plus peripheral balloon
catheter. We then deflated a balloon catheter and removed it. At this
point, I performed cineangiograms and an RAO as well as AP projections. We
were able to see the patient's left internal mammary artery very well. This
was important as it appeared to be used for a bypass graft as there were
several clips down the distribution where the bypass graft was entered in the
patient's left anterior descending coronary artery. I certainly wanted to
make sure that we did not disrupt this in any way. We selected a 7.0 mm
Omnilink balloon expandable peripheral stent catheter, with the stent being
29 mm in length. This stent catheter was then in position. I made sure that
the distal aspect of the stent catheter was just short from the patient
takeoff of the patient's left internal mammary artery. I was satisfied with
the patient position. I inflated the stent catheter very carefully to 12
atmospheres of pressure with balloon inflation for 29 seconds and then
deployed it. It then deflated the stent catheter and removed it. We then
placed a second stent catheter more proximal so that it overlapped the first
stent. The proximal aspect of this stent was noted to be just proximal to
the takeoff, hanging back slightly into the patient's thoracic aorta artery.
I was satisfied with the position. We inflated the stent catheter very
carefully to 12 atmospheres of pressure and balloon inflation of 28 seconds.
We subseuqently post dilated the stents with a 7.0 mm Ultra Thin Diamond
peripheral balloon catheter. Two balloon inflations were made. The first
balloon inflation was 10 atmospheres of pressure, more distally, the second
balloon inflation was 12 atmospheres of pressure, more proximally. We then
deflated the stent high pressure angioplasty balloon catheter and removed it.
Subsequently, angiograms were widely patent, overlapping stented segment in
the patient's proximal and subclavian artery. There was excellent flow in
the distal vessel. There was excellent flow down the patient's left internal
mammary artery as well.
The patient tolerated the procedure quite well. There were no complications
from the procedure.
CONCLUSIONS
1. Thoracic aorta arteriogram filling a totally occluded proximal and
subclavian artery with only a stump noted.
2. Successful implantation of 2 overlapping stents in the proximal left
subclavian artery. Most stents are 7.0 mm OmniLink balloon expandable bare
metal peripheral stents. The long segment of total occlusion of the very
proximal aspect of the left subclavian artery with TIMI-0 flow
preintervention was reduced to no residual narrowing noted with TIMI-3 flow
postintervention.
Was wanting some feed back on this case/second opinion please.
I've come up with:
37236
75625-26,59
I'm not fully seeing the Thoracic Aorta Arteriogram in this report.
PROCEDURE
1. Thoracic aorta arteriogram.
2. Implantation of 2 overlapping 7.0 mm Omnilink balloon-expandable bare
metal stents into the totally occluded proximal left subclavian area.
BRIEF HISTORY
The patient is a very pleasant 82-year-old female who has a rather extensive
past medical history. She has had coronary artery bypass surgery performed
in the past. She has been having severe pain in her left arm for several
years. These symptoms have worsened significantly. She had arterial Doppler
study performed and was found to have a totally occluded left subclavian
artery with reconstitution of the mid left subclavian artery. She also has
had recurrent falls and has history of sick sinus syndrome and has a
permanent pacemaker. After careful discussion of various options, she was
referred for an attempt at possible catheter-based intervention of the left
subclavian artery since she has had symptomatic left subclavian artery
occlusion.
CATHETERIZATION AND INTERVENTION REPORT
The patient was brought to the cardiac catheterization laboratory in very
stable condition. Both groins were carefully prepped and draped in the
routine sterile fashion. We turned our attention to the right coronary
artery. Using 1% Xylocaine, the right femoral artery was anesthetized.
Using a Cook needle, the right femoral artery was entered without difficulty,
and a 5 French sheath was inserted via the Seldinger technique. The sheath
was aspirated and flushed.
A 5-French pigtail catheter was then advanced into the patient's ascending
aorta. A couple of abdominal aortograms were performed in the LAO and AP
projections using digital subtraction angiography. We had some difficulty
visualizing the stump of the left subclavian artery. The left subclavian
artery was totally occluded just past the takeoff of the aorta. We
visualized the brachial cephalic and left common coronary artery very well.
The left subclavian artery appeared to fill faintly from collaterals.
I felt that our chances of successfully recannulizing the left subclavian
artery were not very high, but I felt it was worth the chance. The patient
was very symptomatic. We exchanged that for a long pinnacle destination
sheath, this sheath being 55 cm in length. The tip of this sheath was placed
into the patient's aortic arch and descending thoracic aorta. I then tried
to advanced several different guiding catheters and finally was able to
successfully manipulate the catheter into the ostium of the stump of the
totally occluded left subclavian artery. We were able to successfully
manipulate a 6 French right graft seeker coronary diagnostic catheter.
I then advanced an angioplasty wire and a 3.0 mm coronary balloon catheter.
Unfortunately, we were unable to get very far through the total occlusion
with balloon angioplasty wire. We ended up switching out for a 4-French 0.14
inch crossing seeker catheter. We utilized this in a 0.014 Choice standard
angioplasty exchange wire and were able to manipulate into the total
occlusion somewhat. I then switched out for a couple of different
angioplasty wires. We ended up switching out for a 0.014 Persuader
angioplasty wire and then a Confianza angioplasty exchange wire. We were
able to advance the crosser catheter into the patient's totally occluded left
subclavian artery. We then pulled the angioplasty wire and injected some
contrast. You could see a false lumen, but there was also a faint puff of
dye at what appeared to be the true lumen running off the patient's left
subclavian artery. After a great deal of difficulty, we were able to
manipulate a 0.014 Choice PT floppy exchange wire down this lumen up into the
patient's left subclavian artery. I easily advanced the crossing catheter
over the angioplasty wire. The angioplasty wire was removed. We then
injected dye through the crossing catheter and documented it clearing in the
patient's left subclavian artery at this point.
I then advanced a 0.014 inch Grand Slam angioplasty exchange wire. This was
a stiff wire that would help support a balloon catheter. The crossing
catheter was removed. We then predilated the left subclavian artery, first
with a 3.0 mm Maverick angioplasty coronary balloon catheter. We then
dilated the area with a 4.0 mm Armada peripheral balloon catheter, the
balloon being 40 mm in length. During this time, at the starting of the
interventional procedure, it should be noted that the patient was given 3000
units of IV heparin. We obtained an AZT that was noted to be 176 seconds
during the case period. She was given an additional 2000 units of IV
heparin. She also was given a couple of injections of intraarterial
nitroglycerine. We then continued to dilate the area to help size the
vessel. We dilated the area with a 6.0 mm Fox Plus peripheral balloon
catheter. We then deflated a balloon catheter and removed it. At this
point, I performed cineangiograms and an RAO as well as AP projections. We
were able to see the patient's left internal mammary artery very well. This
was important as it appeared to be used for a bypass graft as there were
several clips down the distribution where the bypass graft was entered in the
patient's left anterior descending coronary artery. I certainly wanted to
make sure that we did not disrupt this in any way. We selected a 7.0 mm
Omnilink balloon expandable peripheral stent catheter, with the stent being
29 mm in length. This stent catheter was then in position. I made sure that
the distal aspect of the stent catheter was just short from the patient
takeoff of the patient's left internal mammary artery. I was satisfied with
the patient position. I inflated the stent catheter very carefully to 12
atmospheres of pressure with balloon inflation for 29 seconds and then
deployed it. It then deflated the stent catheter and removed it. We then
placed a second stent catheter more proximal so that it overlapped the first
stent. The proximal aspect of this stent was noted to be just proximal to
the takeoff, hanging back slightly into the patient's thoracic aorta artery.
I was satisfied with the position. We inflated the stent catheter very
carefully to 12 atmospheres of pressure and balloon inflation of 28 seconds.
We subseuqently post dilated the stents with a 7.0 mm Ultra Thin Diamond
peripheral balloon catheter. Two balloon inflations were made. The first
balloon inflation was 10 atmospheres of pressure, more distally, the second
balloon inflation was 12 atmospheres of pressure, more proximally. We then
deflated the stent high pressure angioplasty balloon catheter and removed it.
Subsequently, angiograms were widely patent, overlapping stented segment in
the patient's proximal and subclavian artery. There was excellent flow in
the distal vessel. There was excellent flow down the patient's left internal
mammary artery as well.
The patient tolerated the procedure quite well. There were no complications
from the procedure.
CONCLUSIONS
1. Thoracic aorta arteriogram filling a totally occluded proximal and
subclavian artery with only a stump noted.
2. Successful implantation of 2 overlapping stents in the proximal left
subclavian artery. Most stents are 7.0 mm OmniLink balloon expandable bare
metal peripheral stents. The long segment of total occlusion of the very
proximal aspect of the left subclavian artery with TIMI-0 flow
preintervention was reduced to no residual narrowing noted with TIMI-3 flow
postintervention.
