PROCEDURES
1. Aortic arch angiogram
2. Selective left subclavian angiogram with the left arm runoff
3. Percutaneous transluminal angioplasty and balloon expandable bare-metal stent placement to left subclavian artery.
PROCEDURE NOTE
Informed consent was obtained after explaining risks and benefits to the patient. Right groin was draped and prepped in the sterile fashion. Patient was premedicated with 3 mg Versed and 125 mg fentanyl altogether IV. After injecting 2% lidocaine in the right groin, right common femoral artery was accessed using micropuncture needle and a 5 French sheath was inserted without any difficulty. Using 5 French angled pigtail catheter, ascending aortogram was performed. Patient was proceeded with intervention of left subclavian artery. Patient remained hemodynamically stable and tolerated procedure well.
AORTIC ARCH AORTOGRAM
Mild atherosclerotic disease was noted in the distal aortic arch. Right brachiocephalic trunk was patent with no significant disease. Left common carotid artery was patent with no significant disease. Left subclavian artery had a proximal 90% stenosis.
PERCUTANEOUS INTERVENTION OF LEFT SUBCLAVIAN ARTERY
6 French 90 cm destination sheath was advanced over Magic torque wire without any difficulty. Heparin was used for anticoagulation. 0.035 Magic torque wire was advanced and lesion of proximal left subclavian artery was successfully crossed without difficulty. 6.0 x 20 mm balloon was advanced and proximal subclavian artery stenosis was predilated at 10 atm. 8.0 x 27 mm express LD balloon expandable stent was advanced the stent was deployed covering lesion of proximal left supplement artery at 8 atm. Stent was postdilated using 8.0 x 20 mm balloon at 10 atm couple of times. Subsequent angiogram revealed wide-open supplement artery with 0% residual stenosis and a brisk antegrade flow in the distal subclavian artery. Left arm runoff was performed and found to have occluded distal ulnar artery and forearm which was reconstituted via collaterals at the level of left wrist. Radial artery flow was normal. She had a palpable good radial pulse at the end of the procedure.
IMPRESSION
1. High-grade 90% stenosis of proximal left supplement artery.
2. Successful percutaneous intervention and balloon expandable stent (BMS) placement to left subclavian artery.
3. Occluded distal left ulnar artery with collaterals -likely chronic
RECOMMENDATIONS
Patient is to continue on her Plavix for minimum 4-6 weeks. Continue aspirin 81 mg as before. Patient had CT angiogram of neck which showed possible distal aortic arch mural thrombus versus penetrating ulcer. She has distal embolization of left ulnar artery which appears chronic with collaterals. Will discuss with hematology regarding need for anticoagulation.
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Thank you for any help.