Occlusion and stenosis of left carotid artery [I65.22 (ICD-10-CM)]
Coronary arteriosclerosis in native artery [I25.10 (ICD-10-CM)]
Other cardiomyopathies (CMS-HCC) [I42.8 (ICD-10-CM)]
Conclusion

63-year-old male with history of severe carotid stenosis known to have left internal carotid artery occlusion, status post right carotid endarterectomy and underwent investigation due to recurrent symptoms. Eventually CTA showed severe stenosis in the area of the right carotid endarterectomy. He was referred for evaluation for right carotid stenting given the fact that he is extremely high surgical risk. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 11:34 AM and monitoring period Ended 12:04 PM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 5 French sheath was inserted in the right femoral artery. A 5 French pigtail catheter was used to perform the arch angiogram. A 5 French VTK catheter was used to selectively engage the left subclavian artery, the left common carotid artery, the right subclavian artery and eventually For selective right carotid angiogram it was directed with a zip wire selectively into the right carotid artery
Finding:
1: Arch angiogram showed a type I aortic arch with no evidence of significant stenosis in the origin of the main vessels
2: Left subclavian injection showed a patent vessel
3: There is an anomalous takeoff of the left vertebral artery from the arch which appears to be patent
4: The left common carotid artery is patent. The left internal carotid artery is 100% occluded.
5: The innominate artery is patent. The right subclavian artery is patent.
6: Selective angiogram of the right carotid artery showed more than 90% stenosis in the right internal carotid artery. Intracerebral injection showed patent intracerebral vessels with significant crossover from left to right.
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Impression:
1. Patent left subclavian, left common carotid, innominate, right subclavian arteries
2. Occlusion of the left internal carotid artery
3. Severe stenosis in the right internal carotid artery at the site of previous carotid endarterectomy
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Plan: Bring the patient back for right internal carotid artery stenting with distal protection device

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