PROCEDURES:
1. Ultrasound guidance, vascular access of the right common femoral
artery, left common femoral artery, and right common femoral vein.
2. Distal aortogram.
3. Bilateral common iliac to common femoral artery angiogram.
4. 12-French Impella 2.5 insertion
5. Temporary pacemaker wire insertion.
6. Left heart catheterization.
7. Coronary angiography
8. CSI rotational atherectomy, mid circumflex artery.
9. Drug-eluting stent integrity resolute 3.5/12 mm mid circumflex artery.
10. Unsuccessful CTO opening of the mid RCA, chronic total occlusion.
11. 02HA3RZ Insertion of external heart assist, percutaneous approach.
12. 5A0221D Assistance with cardiac output usin, continuous.
13. 215 Other heart assist system implant
The risks and benefits of cardiac catheterization and PCI with Impella
support were discussed with the patient, wife, and son. They are agreeable
to the procedure. Consent was obtained.
Time-out was performed. The patient, procedure and physician were identified.
Ultrasound guidance was used to access the right common femoral artery,
right common femoral vein, and left common femoral artery. A 7-French
sheath was introduced to the right common femoral artery and a 6-French
sheath into the right common femoral vein. A 12-French sheath was introduced
into the left common femoral artery. Before the sheath was placed,
Preclose x2 was placed.
A 12-French Impella 2.5 was inserted into the left ventricle without difficulty.
Temporary pacer wire was placed through the right common femoral vein.
Before the Impella implantation, distal aortogram showed no abdominal
aortic aneurysm. Bilateral iliac angiogram showed no significant stenosis
in the right and left common iliac, and external iliac arteries. The
common femoral arteries bilaterally were also without significant disease.
Temporary pacer wire was placed into the right ventricular apex and acceptable
thresholds were obtained.
A 7-French FL4 guide catheter was used to engage the left main. The
ViperWire was advanced into the distal circumflex artery. A CSI 1.25
burr was used to make multiple passes at the 90% stenotic region. An
integrity resolute 3.5/12 mm stent was deployed in the mid segment.
The stent was post dilated with a noncompliant 3.5/12 mm to 12-14 atmospheres.
The previous 80% to 90% stenosis had 0% stenosis at final angiography.
Occlusion of the circumflex artery and injection into the left anterior
descending artery showed no significant ostial disease. Ostial waist
of approximately 20% to 30% is noted. Heavy calcification is noted
in the segment.
Our attention was directed to the right mid CTO. A 7-French JR4 catheter
was used to engage the ostium. Multiple wires including a Choice, run-through,
Fighter, Confianza wires were used, but not able to cross the CTO.
The procedure was subsequently terminated.
The Impella support was weaned. The sheath was removed and the Perclose
sutures were deployed without difficulty. A 6-French Angio-Seal was
used to close the left common femoral artery. Manual pressure was applied
for approximately 15-20 minutes. Good hemostasis was obtained.
The left common femoral artery was also closed with a Perclose. The
common femoral vein sheath was sutured in place and to be removed when
the ACT less than 150 seconds.
IMPRESSION:
1. Successful CSI, drug-eluting stent placement to the mid circumflex artery.
2. Unsuccessful opening of the mid RCA CTO.
The patient tolerated the procedure well and was transferred to the recovery
area in stable condition. The patient awoke without apparent neurologic
deficit.