Thank you all so much!
PROCEDURE PERFORMED:
Right and left heart catheterization, left ventricular angiography, aortic
root angiography, selective right and left coronary angiography, PTCA
and placement of a drug-eluting stent in the posterior marginal branch
of the circumflex, abdominal aortogram with runoff to the iliac, selective
right and left renal angiography, PTA with placement of a bare-metal
7 x 15 Herculink stent in the right renal artery.
DESCRIPTION OF PROCEDURE:
After informed consent, the patient was brought to the cath lab. The
right groin sterilely prepped and draped in the usual manner. Using
modified Seldinger technique, a 7-French venous sheath and a 6-French
arterial sheath placed without difficulty. The patient had monitored
anesthesia care supervised by myself for approximately 2 hours. The
left heart catheterization was performed with a 6-French multipurpose.
HEMODYNAMIC DATA:
The patient is in a normal sinus rhythm with a heart rate of 70 beats
per minute during the procedure. The mean right atrial pressure 15,
Kussmaul sign negative, RV pressure 40/18. Pulmonary artery pressure
40/20, mean of 30, pulmonary capillary wedge pressure 20. No significant
V-wave noted. Arterial pressure 160/75, mean 105, LV pressure 180/26.
OXIMETRIC DATA:
Mean arterial saturation 90%. Mean mixed venous saturation was 69%.
Cardiac output 5.5 L/minute with an index of 2.7 L/minute per m2.
LEFT VENTRICULAR ANGIOGRAPHY:
Left ventricular angiography was performed in a single RAO projection.
Left ventricle is well opacified with dye. There is mild concentric
hypertrophy. Systolic function normal. Ejection fraction 65%. No
wall motion abnormalities seen. No mitral regurgitation noted. Next,
the aortic root angiogram was performed in a steep LAO projection.
The aortic root is well opacified with dye. The valve appears to be
trileaflet and heavily calcified. There was trivial aortic insufficiency.
No evidence of dissection. Minimal annular aortic ectasia noted.
CORONARY ANGIOGRAPHY:
Coronary angiography is performed in multiple projections.
1. The right coronary artery is a moderate-sized dominant vessel.
There is diffuse atherosclerotic plaquing, 30% focal stenosis in the
proximal portion with a 50% stenosis at the acute margin. Luminal irregularities
are noted throughout the distal system.
2. Left main coronary artery is a moderate-sized vessel, arising the
left cusp, is angiographically normal and it ends in a bifurcation.
3. The circumflex is a moderate-sized nondominant vessel. The origin
of the circumflex is normal. It bifurcates into a large posterior marginal
branch and a medial marginal branch. The posterior marginal branch
has a 90+ percent stenosis in its mid portion at the level of the groove
branch origin.
4. The left anterior descending artery is a moderate to large blood
vessel. The origin of the LAD is normal. It immediately gives rise
to a diagonal branch, which has a 50% to 70% stenosis in its proximal
portion. This vessel is approximately 2 mm in diameter. As the LAD
continues, there appears to be myocardial bridging in its mid portion,
which is mild, diffuse, but nonobstructive disease as noted in the mid
and distal LAD.
An abdominal aortogram was performed in a single AP projection. Abdominal
aorta is well opacified with dye. The superior mesenteric artery is
patent. There is a 20% to 30% stenosis in the left renal artery. There
is a 70% to 80% stenosis in the right renal artery. Diffuse plaquing
is noted in the distal aorta and common iliac arteries. There is a
focal stenosis of 60% in the right internal iliac artery. The left
internal iliac artery has moderate nonobstructive plaquing. There is
diffuse plaquing in the external iliacs bilaterally, but no critical
stenoses noted. At the end of the case, there was no significant gradient
on pullback.
PCI: We selected a 6-French JL4 guiding catheter. The patient was bolused
with Angiomax and a drip was begun. We used an 0.014 wire to cross
the lesion. The lesion was dilated with a 2 x 20 Emerge. We then stented
the lesion with 2.5 x 24 PROMUS, final MLD 2.43. There was some spasm
proximal to the stent, which was relieved with intracoronary nitroglycerin.
Next, we selected a 6-French renal guide. We stuck with coronary system.
The right renal artery was dilated with a 7 x 20 Aviator. We then
stented the right renal artery with a 7 x 15 Herculink bare-metal stent.
Final MLD 7.23 and 0% residual stenosis.
IMPRESSIONS:
1. Successful stenting of the circumflex, leaving 0% residual stenosis.
There is mild disease both proximal and distal to the sent.
2. 70% diagonal branch.
3. Moderate disease in the proximal and mid right coronary artery.
4. Successful renal angioplasty and stenting of the right renal artery.
PLANS:
The patient needs maximum plaque stabilization therapy and smoking cessation