OPENSHAW
Guru
HOW WOULD THIS BE CODED, HELP! THANK YOU!
Pre-op and Post-op Diagnosis: left subclavian stenosis and subclavian steal syndrome
Description of the procedure: The patient was brought to the Cardiac Catheterization Laboratory. After premedication with fentanyl and Versed, both groins were prepped and draped in the usual sterile fashion. After palpation of the right common femoral artery, the skin above this region was infiltrated with 2% lidocaine. Right common femoral artery was then accessed using the right fluoroscopic visualization under modified Seldinger technique after which a #5 French sheath was placed without difficulty obtaining a good brisk flow and adequate waveforms in the monitor. Then, a #5 French JL4 catheter was advanced over the wire through the sheath into the ascending aorta and left subclavian artery was engaged without difficulty. After aspirated the catheter, the left subclavian angiography was done and multiple views were obtained. It was revealed to be 99% proximal occlusion of the left subclavian with evidence of competitive flow from the left vertebral artery into the distal subclavian. After accessing these findings, intervention was decided to be done. Initial attempts to cross lesion was done with a Wholey wire and a glidewire, but the proximal lesion of the mid subclavian was unable to be crossed with this wire.
It was then decided to upsize the size of the catheter and sheath and therefore the JL4 diagnostic catheter was removed over the wire. Subsequently, the #5 French sheath that was placed in the right common femoral artery was upsized to the #6 French sheath. After which, a #6 French JR4 catheter was then advanced over the wire without difficulty and after aspiration, left subclavian artery was engaged. JR4 catheter was removed prior to engaging the vessel to the left subclavian artery and after obtaining angiography of the left subclavian, a PT Graphix wire was advanced through the JR4 catheter into the left subclavian artery. It was advanced without difficulty and the tip was parked in the distal subclavian artery. After the wire was advanced, an Emerge 4.0 x 20 mm balloon was advanced over the wire into the proximal segment of the left subclavian and this balloon was inflated without any problems. Then, an Emerge 1.5 x 20 mm balloon was advanced, but was unable to cross the lesion and was removed. However, there was a question that the entry point of the PT Graphix wire had been done in the subintimal portion right at the area of the left subclavian with quick reentery into the lumen. Therefore, a second PT Graphix wire was advanced through the catheter into the left subclavian to what appeared to be the tru lumen of the left subclavian. This second PT Graphix crossed the lesion without any difficulty and the distal tip was parked in the mid to distal subclavian. Then, a Sterling 6 x 40 balloon was advanced over the second PT Graphix wire into the left subclavian artery and it was parked in the proximal segment of the left subclavian without any complications seen. This second balloon was felt to be in the tru lumen of the left subclavian artery and subsequent angiography of the left subclavian revealed no evidence of dissection, perforation, or any complications. This balloon was removed and the first PT Graphix wire was also removed when it was exchanged for a 0.035 Storq wire that was advanced to the JL4 catheter into the subclavian artery and it was able to cross the lesion without any difficulty. The wire tip was then parked in the distal subclavian for adequate support. At this point, with a 0.035 system, JR4 catheter and PT Graphix wire were then removed and it was decided to upsize the sheath and #6 French sheath that was placed in the right common femoral artery was removed over the 0.035 Storq wire and it was exchanged for a #7 French 90 cm Destination sheath. That was advanced over the wire and placed in the right common femoral artery without difficulties. With Destination sheath in place and the Storq wire in the distal subclavian, a Mustang 6 x 40 mm balloon was then advanced over the Storq wire and it was placed in the proximal subclavian. After which, it was inflated without any complications. Subsequent angiography of the left subclavian revealed no evidence of dissection, perforation, or any complications after initial balloon inflation. The Mustang balloon was removed over the wire and Genesis 6 x 39 mm stent was advanced over the Storq wire, and after the confirmation of the appropriate position, the stent was deployed in the proximal subclavian artery without any complications.
Angiography revealed no evidence of dissection or perforation, but it was felt a need for pulmonary dialation which was accomplished after removing the stent delivery system over the wire with a Mustang 7 x 40 mm balloon that was used for post-dialation in the proximal segment of the subclavian where the stent had been previously deployed obtaining excellent apposition of the distal segment of the stent and there was felt to be adequate apposition of the proximal segment of the stent. Angiography after the post-dilation with the balloon revealed no dissections, perforations, or any complications at this point. Angiography in fact revealed adequate brisk flow to the left subclavian and no further evidence of competitive flow from the vertebral artery and in fact demonstrated antegrade flow into the left vertebral artery. Initial translesion gradient was obtained before any dilation with any balloon was roughly to be 30 to 40 mmHg and this gradient was decrease about 10 mmHg after dilation, stentiong, and post dilation in the proximal segment of the subclavian. Final angiography was done in the left subclavian and showed an adequate integrity of the vessels without any complications. At this point, the JL4 catheter was then removed over the wire and the Destination sheath was then removed without any complications over the wire and a #7 French short sheath was placed instead without any complications. After assessing right common femoral angiography, it was deemed suitable for placement of a closure device and after confirmation of adequate ACT level, then Mynx closure device was then placed in the right common femoral artery achieving adequate hemostasis. It was important to note that throughout the procedure, frequent and sequential neurological assessment was drawn without any abnormal findings throughout the procedure. No gross neurological deficit was seen throughout the procedure. The patient tolerated the procedure well and she was then transferred to the holding area with no complications.
Findings:
1. 99% proximal subclavian stenosis with evidence of a 30 to 40 mm translesional gradient and evidnece of comparative flow from the left vertebral artery.
2. After balloon dilation and stenting procedure, translesion gradient decreased to less than 10 mmHg and evidence of anterograde flow into the left vertebral with no evidence of comparable flow from the vertebral artery. LIMA artery was patent throughout the entire procedure.
Conclusions and Recommendations: There was evidence of significant proximal left subclavian artery stenosis with a subtotal occlusion in the left subclavian. The proximal left subclavian with evidence of very high translesional gradient and evidence of competitive flow from the left vertebral artery, which probably would explain the symptomatology and a left subclavian steal syndrome.
After stenting, the translesional gradient has decreased and no further evidence of competitive flow has been seen. At this point, the lesion has been stented with excellent results and we will continue with medical therapy optimization and risk factor control. The patient will be loaded with clopigrogel and she will require maintenance therapy with off clopidogrel along with aspirin and antiplatelet therapy. She will continue to have medical therapy optimization and aggressive cardiovascular risk factor control and lifestyle modifications. All these findings were explained to the patient and the family and they all voiced understanding.
THANK YOU!!!!!
Pre-op and Post-op Diagnosis: left subclavian stenosis and subclavian steal syndrome
Description of the procedure: The patient was brought to the Cardiac Catheterization Laboratory. After premedication with fentanyl and Versed, both groins were prepped and draped in the usual sterile fashion. After palpation of the right common femoral artery, the skin above this region was infiltrated with 2% lidocaine. Right common femoral artery was then accessed using the right fluoroscopic visualization under modified Seldinger technique after which a #5 French sheath was placed without difficulty obtaining a good brisk flow and adequate waveforms in the monitor. Then, a #5 French JL4 catheter was advanced over the wire through the sheath into the ascending aorta and left subclavian artery was engaged without difficulty. After aspirated the catheter, the left subclavian angiography was done and multiple views were obtained. It was revealed to be 99% proximal occlusion of the left subclavian with evidence of competitive flow from the left vertebral artery into the distal subclavian. After accessing these findings, intervention was decided to be done. Initial attempts to cross lesion was done with a Wholey wire and a glidewire, but the proximal lesion of the mid subclavian was unable to be crossed with this wire.
It was then decided to upsize the size of the catheter and sheath and therefore the JL4 diagnostic catheter was removed over the wire. Subsequently, the #5 French sheath that was placed in the right common femoral artery was upsized to the #6 French sheath. After which, a #6 French JR4 catheter was then advanced over the wire without difficulty and after aspiration, left subclavian artery was engaged. JR4 catheter was removed prior to engaging the vessel to the left subclavian artery and after obtaining angiography of the left subclavian, a PT Graphix wire was advanced through the JR4 catheter into the left subclavian artery. It was advanced without difficulty and the tip was parked in the distal subclavian artery. After the wire was advanced, an Emerge 4.0 x 20 mm balloon was advanced over the wire into the proximal segment of the left subclavian and this balloon was inflated without any problems. Then, an Emerge 1.5 x 20 mm balloon was advanced, but was unable to cross the lesion and was removed. However, there was a question that the entry point of the PT Graphix wire had been done in the subintimal portion right at the area of the left subclavian with quick reentery into the lumen. Therefore, a second PT Graphix wire was advanced through the catheter into the left subclavian to what appeared to be the tru lumen of the left subclavian. This second PT Graphix crossed the lesion without any difficulty and the distal tip was parked in the mid to distal subclavian. Then, a Sterling 6 x 40 balloon was advanced over the second PT Graphix wire into the left subclavian artery and it was parked in the proximal segment of the left subclavian without any complications seen. This second balloon was felt to be in the tru lumen of the left subclavian artery and subsequent angiography of the left subclavian revealed no evidence of dissection, perforation, or any complications. This balloon was removed and the first PT Graphix wire was also removed when it was exchanged for a 0.035 Storq wire that was advanced to the JL4 catheter into the subclavian artery and it was able to cross the lesion without any difficulty. The wire tip was then parked in the distal subclavian for adequate support. At this point, with a 0.035 system, JR4 catheter and PT Graphix wire were then removed and it was decided to upsize the sheath and #6 French sheath that was placed in the right common femoral artery was removed over the 0.035 Storq wire and it was exchanged for a #7 French 90 cm Destination sheath. That was advanced over the wire and placed in the right common femoral artery without difficulties. With Destination sheath in place and the Storq wire in the distal subclavian, a Mustang 6 x 40 mm balloon was then advanced over the Storq wire and it was placed in the proximal subclavian. After which, it was inflated without any complications. Subsequent angiography of the left subclavian revealed no evidence of dissection, perforation, or any complications after initial balloon inflation. The Mustang balloon was removed over the wire and Genesis 6 x 39 mm stent was advanced over the Storq wire, and after the confirmation of the appropriate position, the stent was deployed in the proximal subclavian artery without any complications.
Angiography revealed no evidence of dissection or perforation, but it was felt a need for pulmonary dialation which was accomplished after removing the stent delivery system over the wire with a Mustang 7 x 40 mm balloon that was used for post-dialation in the proximal segment of the subclavian where the stent had been previously deployed obtaining excellent apposition of the distal segment of the stent and there was felt to be adequate apposition of the proximal segment of the stent. Angiography after the post-dilation with the balloon revealed no dissections, perforations, or any complications at this point. Angiography in fact revealed adequate brisk flow to the left subclavian and no further evidence of competitive flow from the vertebral artery and in fact demonstrated antegrade flow into the left vertebral artery. Initial translesion gradient was obtained before any dilation with any balloon was roughly to be 30 to 40 mmHg and this gradient was decrease about 10 mmHg after dilation, stentiong, and post dilation in the proximal segment of the subclavian. Final angiography was done in the left subclavian and showed an adequate integrity of the vessels without any complications. At this point, the JL4 catheter was then removed over the wire and the Destination sheath was then removed without any complications over the wire and a #7 French short sheath was placed instead without any complications. After assessing right common femoral angiography, it was deemed suitable for placement of a closure device and after confirmation of adequate ACT level, then Mynx closure device was then placed in the right common femoral artery achieving adequate hemostasis. It was important to note that throughout the procedure, frequent and sequential neurological assessment was drawn without any abnormal findings throughout the procedure. No gross neurological deficit was seen throughout the procedure. The patient tolerated the procedure well and she was then transferred to the holding area with no complications.
Findings:
1. 99% proximal subclavian stenosis with evidence of a 30 to 40 mm translesional gradient and evidnece of comparative flow from the left vertebral artery.
2. After balloon dilation and stenting procedure, translesion gradient decreased to less than 10 mmHg and evidence of anterograde flow into the left vertebral with no evidence of comparable flow from the vertebral artery. LIMA artery was patent throughout the entire procedure.
Conclusions and Recommendations: There was evidence of significant proximal left subclavian artery stenosis with a subtotal occlusion in the left subclavian. The proximal left subclavian with evidence of very high translesional gradient and evidence of competitive flow from the left vertebral artery, which probably would explain the symptomatology and a left subclavian steal syndrome.
After stenting, the translesional gradient has decreased and no further evidence of competitive flow has been seen. At this point, the lesion has been stented with excellent results and we will continue with medical therapy optimization and risk factor control. The patient will be loaded with clopigrogel and she will require maintenance therapy with off clopidogrel along with aspirin and antiplatelet therapy. She will continue to have medical therapy optimization and aggressive cardiovascular risk factor control and lifestyle modifications. All these findings were explained to the patient and the family and they all voiced understanding.
THANK YOU!!!!!
