bhargavi
Guru
PROCEDURES PERFORMED
Cardiac catheterization and percutaneous interventional procedure.
CLINICAL INDICATION
Acute ST segment elevation myocardial infarction.
CLINICAL HISTORY
Mr is a 70-year-old man with a history of dementia who was admitted
to the Kent General Hospital with new onset atrial fibrillation and severe
systemic hypertension. He also ruled in for a small non-ST segment elevation
myocardial infarction. Additionally he had evidence of mild renal
insufficiency. He has been admitted for the last several days and started on
appropriate antihypertensive therapies as well as rate control therapy for his
atrial fibrillation. Last evening he had approximately two episodes of long
pauses requiring rapid responses being called on the floor and resulting in
transfer to the Intensive Care Unit. The patient then had yet another episode
with evidence of ventricular tachycardia requiring brief cardiopulmonary
resuscitation. He was noted on a followup electrocardiogram to have ST
elevations described primarily in the inferior leads with reciprocal changes
although on my review of the ECG there was clear, diffuse anterolateral ST
elevation as well as inferior changes and some reciprocal high lateral changes
consistent with an evolving acute myocardial infarction. Despite this the
patient was allegedly asymptomatic and had acute worsening of his renal
function with a creatinine that had increased from 2.1 to 2.9 and an elevated
serum potassium level of 5.4. I was asked by Dr. to perform urgent
coronary angiography to assess the patient's cardiovascular status. Plans were
also in place for the patient to have permanent pacemaker placement due to his
bradycardic episodes by Dr. although it was felt that assessment of his
coronary anatomy took early precedence. I was initially reluctant to perform
this procedure given the patient's acute renal insufficiency before rechecking
a creatinine and potassium level in order to make sure that there was not
significant life threatening hyperkalemia. Once the repeat values returned and
troponin I returned elevated over 100, we elected at that point to proceed with
coronary angiography and possible intervention. We also planned on placing a
temporary transvenous pacer. Consent was obtained from the patient's next of
kin as he was unable to consent on his own.
TECHNIQUE
After obtaining consent from the family, the patient was prepped and draped in
the usual fashion. Approximately 10 ml of 2% lidocaine anesthesia was
administered to the right groin prior to placement of the arterial and venous
sheaths. Under fluoroscopic guidance and using modified Seldinger technique a
6-French arterial and 6-French venous sheath were placed in the right femoral
artery and vein respectively. We then obtained a 5-French unipolar temporary
pacing catheter which was advanced without difficulty into the right
ventricular apex. Capture was then confirmed by setting the pacer to a heart
rate of 90 which did demonstrate consistent capture. Pacing catheter was then
sutured in place and turned to a backup rate of 60 beats per minute. We then
proceeded with coronary angiography utilizing hand injections initially of
Visipaque contrast through 6-French FL4 and FR4 catheters. Due to inability to
locate the right coronary artery we did obtain a 6-French AR modified catheter
and then followed this by performing ascending aortography utilizing a 6-French
angled pigtail catheter.
FINDINGS
1. The aortic pressure was 110/81 mmHg.
2. Left main. The left main was a large vessel which bifurcated into the
left anterior descending and left circumflex branches. The left main was
free of disease.
3. Left anterior descending The left anterior descending was a large vessel
which wrapped the coronary apex and gave rise to a total of two major
diagonal branches. In the proximal vessel just beyond the origin of the
first diagonal branch there was a tubular 30 to 40% stenosis. In the mid
to distal vessel there was a more focal area of 95 to 99% stenosis with
TIMI grade III flow beyond. A second diagonal branch arose from the mid
vessel. It was small to moderate in caliber and free of significant
atherosclerotic disease.
4. Left circumflex The left circumflex is a large, anatomically dominant
vessel which gives rise to a total of two major obtuse marginal branches
as well as a posterior descending and posterior lateral arcade. There was
proximal osteal 20% disease in the left circumflex. The first obtuse
marginal branch was moderate to large in caliber and has osteal to
proximal 30% disease. A subbranch of the first obtuse marginal branch was
moderate in caliber and on initial angiography appeared to have diffuse 70
to 80% stenosis, however, at end procedure after administration of
multiple doses of intracoronary nitroglycerin, this vessel appeared to
have patchy 30 to 40% disease. The continuation of the left circumflex in
the atrioventricular groove led to a medium sized posterior descending and
posterolateral system which was free of significant atherosclerotic
disease.
5. Right coronary artery The right coronary artery was not able to be
visualized on injection with either the FR4 or AR modified catheters. We
then, therefore, performed ascending aortography utilizing a 6-French
angled pigtail catheter. The right coronary artery was still not
visualized and is presumably either chronically occluded and
non- dominant or congenitally absent.
After identification of critical disease involving the late mid left anterior
descending we elected to proceed percutaneous intervention. The patient
unfortunately was intermittently combative throughout the procedure and was
only briefly responding calmed down to verbal cues necessitating placement of
bilateral wrist restraints as well as leg restraints.
Despite this the patient still did a significant amount of moving during the
procedure. His mental status was not completely clear even while up in the
Intensive Care Unit. I was reluctant to administer intravenous midazolam for
sedation as I felt that this would worsen the situation but I did administer 1
milligram of morphine which did not appear to confer any significant benefit.
Ultimately, I did contact anesthesiology who was able to
provide additional sedation with 30 mcg of propofol intravenously and 10
milligrams of etomidate intravenously.
The existing 6-French sheaths were both maintained in place as was a 5-French
pacing catheter. We then administered heparin at a dose of 5000 units by
intravenous bolus in order to achieve an activated clotting time in excess of
200 seconds. At termination of the procedure and after transfer back to the
Intensive Care Unit, a nasogastric tube was placed and a 600 milligrams Plavix
load was administered. The left main was then selectively engaged utilizing a
6-French EBU 3.75 guide catheter. We then obtained a 180 cm Asahi Prowater
straight wire which was advanced without difficulty to the apical left anterior
descending. We performed pre-dilatation of the culprit stenosis utilizing a 2.0
x 12 millimeter Emerge balloon to 10 atmospheres of pressure. Followup
angiography after balloon angioplasty revealed evidence of a linear dissection
at the site of balloon angioplasty. We then proceeded directly to stenting,
obtaining, advancing and deploying a 2.25 x 23 millimeters mini-vision bare
metal stent in the left anterior descending deployed to 16 atmospheres of
pressure. Followup angiography revealed an excellent result with InStent with
areas of what appeared to be spasm at the proximal and distal stent edges. We
then administered a total of 200 mcg of intracoronary nitroglycerin into the
left coronary system and this revealed resolution of these areas of spasm.
There was an excellent angiographic result with no residual stenosis and no
evidence of proximal or distal edge dissection, thrombosis or spasm with TIMI
grade III flow and the patient was asymptomatic. We then concluded this portion
of the procedure.
We performed final angiography of the left coronary system through the guide
catheter and there was no change in the flow dynamics in the left anterior
descending, however, there appeared to be a new area of irregularity within the
left main. We removed the guide catheter and performed additional angiography
of the left main through the aforementioned 6-French FL4 diagnostic catheter
which did, indeed, confirm an area of disruption which at this time was
non-flow limiting in the left main consistent with a left main dissection. We
surmised that this dissection occurred as a result of significant patient
motion during the body of the procedure which resulted in physical disruption
of the left main. Again, fortunately there was no evidence of a change in flow
dynamics nor any change in blood pressure or perfusion on the part of the
patient at this point in time. However, given concerns about the appearance of
the left main we rapidly considered our options. We did contact cardiovascular surgery for evaluation although given the
patient's acute renal failure, his mental status, his advanced dementia and
other comorbidities we felt that it would be highly unlikely that this patient
would be a surgical candidate. We
therefore elected to perform stenting of the left main. Fortunately the
dissection was in the mid portion of the left main and did not involve the
distal left main bifurcation. The diagnostic catheter was removed and the
6-French EBU 3.75 guide catheter was again readvanced into the left main. We
then readvanced our Asahi Prowater wire into the distal aspect of the left
circumflex beyond the left main lesion. We elected at that point to perform
direct stenting of the left main utilizing a 4.0 x 12 millimeter Vision stent.
This stent was deployed to 12 atmospheres of pressure in the mid to distal left
main prior to the bifurcation. Followup angiography after stent deployment
revealed a marked improvement in the overall angiographic appearance of the
vessel with some slight under sizing of the proximal stent edge from the stent
balloon. We therefore elected to perform post dilation of the proximal and mid
segments of the stent utilizing a 4.0 x 6 mm NC Quantum Apex balloon up to 20
atmospheres of pressure times two overlapping inflations. Final angiography
of the left main after sent deployment and post dilatation revealed an
excellent angiographic result with no significant residual stenosis and no
evidence of proximal or distal edge dissection, thrombosis or spasm. Again,
there was TIMI grade III flow in the vessel and the patient was free of
symptoms. We elected again, therefore, to conclude the angioplasty and
angiographic procedure. The coronary guidewire was removed and final
angiography revealed a stable appearance of the left main with no evidence of
proximal to distal edge dissection, thrombosis or spasm. We then concluded the
angioplasty procedure as well.
Nonselective injection of the right ileofemoral system performed during the
procedure revealed acceptable positioning of the arterial sheath in the distal
right common femoral artery above the common femoral bifurcation. There was no
angiographic evidence of disease at the site of sheath insertion and given that
the patient was hemodynamically stable and had been noncompliant with remaining
spill during the procedure we felt that placement of a closure device would be
warranted. We therefore placed a 6-French Angio-Seal device for hemostasis. The
venous sheath and pacing catheter were then sutured in place and covered with a
Tegaderm dressing and the patient was transferred back to the Intensive Care
Unit in stable condition.
IMPRESSION
1. Severe mid-distal left anterior descending disease status post successful
angioplasty and bare metal stenting.
2. Iatrogenic left main dissection related to patient motion and guide
catheter status post successful bare metal stenting of left main.
3. Bradycardia status post successful placement of 5-French pacing catheter.
4. Status post Angio-Seal placement.
PLAN
1. Aspirin for life.
2. Plavix indefinitely.
3. Aggressive risk factor modification.
4. Wean dopamine and pacing catheter as clinically indicated.
5. Other plans will depend upon the patient's clinical course.
should i do 93454,92928,92929 baremetal stents or should i do 93454,92941,92928
thank you in advance
Cardiac catheterization and percutaneous interventional procedure.
CLINICAL INDICATION
Acute ST segment elevation myocardial infarction.
CLINICAL HISTORY
Mr is a 70-year-old man with a history of dementia who was admitted
to the Kent General Hospital with new onset atrial fibrillation and severe
systemic hypertension. He also ruled in for a small non-ST segment elevation
myocardial infarction. Additionally he had evidence of mild renal
insufficiency. He has been admitted for the last several days and started on
appropriate antihypertensive therapies as well as rate control therapy for his
atrial fibrillation. Last evening he had approximately two episodes of long
pauses requiring rapid responses being called on the floor and resulting in
transfer to the Intensive Care Unit. The patient then had yet another episode
with evidence of ventricular tachycardia requiring brief cardiopulmonary
resuscitation. He was noted on a followup electrocardiogram to have ST
elevations described primarily in the inferior leads with reciprocal changes
although on my review of the ECG there was clear, diffuse anterolateral ST
elevation as well as inferior changes and some reciprocal high lateral changes
consistent with an evolving acute myocardial infarction. Despite this the
patient was allegedly asymptomatic and had acute worsening of his renal
function with a creatinine that had increased from 2.1 to 2.9 and an elevated
serum potassium level of 5.4. I was asked by Dr. to perform urgent
coronary angiography to assess the patient's cardiovascular status. Plans were
also in place for the patient to have permanent pacemaker placement due to his
bradycardic episodes by Dr. although it was felt that assessment of his
coronary anatomy took early precedence. I was initially reluctant to perform
this procedure given the patient's acute renal insufficiency before rechecking
a creatinine and potassium level in order to make sure that there was not
significant life threatening hyperkalemia. Once the repeat values returned and
troponin I returned elevated over 100, we elected at that point to proceed with
coronary angiography and possible intervention. We also planned on placing a
temporary transvenous pacer. Consent was obtained from the patient's next of
kin as he was unable to consent on his own.
TECHNIQUE
After obtaining consent from the family, the patient was prepped and draped in
the usual fashion. Approximately 10 ml of 2% lidocaine anesthesia was
administered to the right groin prior to placement of the arterial and venous
sheaths. Under fluoroscopic guidance and using modified Seldinger technique a
6-French arterial and 6-French venous sheath were placed in the right femoral
artery and vein respectively. We then obtained a 5-French unipolar temporary
pacing catheter which was advanced without difficulty into the right
ventricular apex. Capture was then confirmed by setting the pacer to a heart
rate of 90 which did demonstrate consistent capture. Pacing catheter was then
sutured in place and turned to a backup rate of 60 beats per minute. We then
proceeded with coronary angiography utilizing hand injections initially of
Visipaque contrast through 6-French FL4 and FR4 catheters. Due to inability to
locate the right coronary artery we did obtain a 6-French AR modified catheter
and then followed this by performing ascending aortography utilizing a 6-French
angled pigtail catheter.
FINDINGS
1. The aortic pressure was 110/81 mmHg.
2. Left main. The left main was a large vessel which bifurcated into the
left anterior descending and left circumflex branches. The left main was
free of disease.
3. Left anterior descending The left anterior descending was a large vessel
which wrapped the coronary apex and gave rise to a total of two major
diagonal branches. In the proximal vessel just beyond the origin of the
first diagonal branch there was a tubular 30 to 40% stenosis. In the mid
to distal vessel there was a more focal area of 95 to 99% stenosis with
TIMI grade III flow beyond. A second diagonal branch arose from the mid
vessel. It was small to moderate in caliber and free of significant
atherosclerotic disease.
4. Left circumflex The left circumflex is a large, anatomically dominant
vessel which gives rise to a total of two major obtuse marginal branches
as well as a posterior descending and posterior lateral arcade. There was
proximal osteal 20% disease in the left circumflex. The first obtuse
marginal branch was moderate to large in caliber and has osteal to
proximal 30% disease. A subbranch of the first obtuse marginal branch was
moderate in caliber and on initial angiography appeared to have diffuse 70
to 80% stenosis, however, at end procedure after administration of
multiple doses of intracoronary nitroglycerin, this vessel appeared to
have patchy 30 to 40% disease. The continuation of the left circumflex in
the atrioventricular groove led to a medium sized posterior descending and
posterolateral system which was free of significant atherosclerotic
disease.
5. Right coronary artery The right coronary artery was not able to be
visualized on injection with either the FR4 or AR modified catheters. We
then, therefore, performed ascending aortography utilizing a 6-French
angled pigtail catheter. The right coronary artery was still not
visualized and is presumably either chronically occluded and
non- dominant or congenitally absent.
After identification of critical disease involving the late mid left anterior
descending we elected to proceed percutaneous intervention. The patient
unfortunately was intermittently combative throughout the procedure and was
only briefly responding calmed down to verbal cues necessitating placement of
bilateral wrist restraints as well as leg restraints.
Despite this the patient still did a significant amount of moving during the
procedure. His mental status was not completely clear even while up in the
Intensive Care Unit. I was reluctant to administer intravenous midazolam for
sedation as I felt that this would worsen the situation but I did administer 1
milligram of morphine which did not appear to confer any significant benefit.
Ultimately, I did contact anesthesiology who was able to
provide additional sedation with 30 mcg of propofol intravenously and 10
milligrams of etomidate intravenously.
The existing 6-French sheaths were both maintained in place as was a 5-French
pacing catheter. We then administered heparin at a dose of 5000 units by
intravenous bolus in order to achieve an activated clotting time in excess of
200 seconds. At termination of the procedure and after transfer back to the
Intensive Care Unit, a nasogastric tube was placed and a 600 milligrams Plavix
load was administered. The left main was then selectively engaged utilizing a
6-French EBU 3.75 guide catheter. We then obtained a 180 cm Asahi Prowater
straight wire which was advanced without difficulty to the apical left anterior
descending. We performed pre-dilatation of the culprit stenosis utilizing a 2.0
x 12 millimeter Emerge balloon to 10 atmospheres of pressure. Followup
angiography after balloon angioplasty revealed evidence of a linear dissection
at the site of balloon angioplasty. We then proceeded directly to stenting,
obtaining, advancing and deploying a 2.25 x 23 millimeters mini-vision bare
metal stent in the left anterior descending deployed to 16 atmospheres of
pressure. Followup angiography revealed an excellent result with InStent with
areas of what appeared to be spasm at the proximal and distal stent edges. We
then administered a total of 200 mcg of intracoronary nitroglycerin into the
left coronary system and this revealed resolution of these areas of spasm.
There was an excellent angiographic result with no residual stenosis and no
evidence of proximal or distal edge dissection, thrombosis or spasm with TIMI
grade III flow and the patient was asymptomatic. We then concluded this portion
of the procedure.
We performed final angiography of the left coronary system through the guide
catheter and there was no change in the flow dynamics in the left anterior
descending, however, there appeared to be a new area of irregularity within the
left main. We removed the guide catheter and performed additional angiography
of the left main through the aforementioned 6-French FL4 diagnostic catheter
which did, indeed, confirm an area of disruption which at this time was
non-flow limiting in the left main consistent with a left main dissection. We
surmised that this dissection occurred as a result of significant patient
motion during the body of the procedure which resulted in physical disruption
of the left main. Again, fortunately there was no evidence of a change in flow
dynamics nor any change in blood pressure or perfusion on the part of the
patient at this point in time. However, given concerns about the appearance of
the left main we rapidly considered our options. We did contact cardiovascular surgery for evaluation although given the
patient's acute renal failure, his mental status, his advanced dementia and
other comorbidities we felt that it would be highly unlikely that this patient
would be a surgical candidate. We
therefore elected to perform stenting of the left main. Fortunately the
dissection was in the mid portion of the left main and did not involve the
distal left main bifurcation. The diagnostic catheter was removed and the
6-French EBU 3.75 guide catheter was again readvanced into the left main. We
then readvanced our Asahi Prowater wire into the distal aspect of the left
circumflex beyond the left main lesion. We elected at that point to perform
direct stenting of the left main utilizing a 4.0 x 12 millimeter Vision stent.
This stent was deployed to 12 atmospheres of pressure in the mid to distal left
main prior to the bifurcation. Followup angiography after stent deployment
revealed a marked improvement in the overall angiographic appearance of the
vessel with some slight under sizing of the proximal stent edge from the stent
balloon. We therefore elected to perform post dilation of the proximal and mid
segments of the stent utilizing a 4.0 x 6 mm NC Quantum Apex balloon up to 20
atmospheres of pressure times two overlapping inflations. Final angiography
of the left main after sent deployment and post dilatation revealed an
excellent angiographic result with no significant residual stenosis and no
evidence of proximal or distal edge dissection, thrombosis or spasm. Again,
there was TIMI grade III flow in the vessel and the patient was free of
symptoms. We elected again, therefore, to conclude the angioplasty and
angiographic procedure. The coronary guidewire was removed and final
angiography revealed a stable appearance of the left main with no evidence of
proximal to distal edge dissection, thrombosis or spasm. We then concluded the
angioplasty procedure as well.
Nonselective injection of the right ileofemoral system performed during the
procedure revealed acceptable positioning of the arterial sheath in the distal
right common femoral artery above the common femoral bifurcation. There was no
angiographic evidence of disease at the site of sheath insertion and given that
the patient was hemodynamically stable and had been noncompliant with remaining
spill during the procedure we felt that placement of a closure device would be
warranted. We therefore placed a 6-French Angio-Seal device for hemostasis. The
venous sheath and pacing catheter were then sutured in place and covered with a
Tegaderm dressing and the patient was transferred back to the Intensive Care
Unit in stable condition.
IMPRESSION
1. Severe mid-distal left anterior descending disease status post successful
angioplasty and bare metal stenting.
2. Iatrogenic left main dissection related to patient motion and guide
catheter status post successful bare metal stenting of left main.
3. Bradycardia status post successful placement of 5-French pacing catheter.
4. Status post Angio-Seal placement.
PLAN
1. Aspirin for life.
2. Plavix indefinitely.
3. Aggressive risk factor modification.
4. Wean dopamine and pacing catheter as clinically indicated.
5. Other plans will depend upon the patient's clinical course.
should i do 93454,92928,92929 baremetal stents or should i do 93454,92941,92928
thank you in advance