PROCEDURES PERFORMED:
1. Selective right and left coronary angiography.
2. Aortoiliac angiography.
3. Intravascular ultrasound of the bilateral common femoral arteries to the
common iliac arteries.
INDICATION: Severe aortic stenosis and preoperative evaluation prior to TAVR.
BRIEF HISTORY: Ms. _____ is an 85-year-old woman with severe aortic
stenosis. She is deemed to be a high surgical risk for surgical aortic valve
replacement. She is undergoing workup for transcatheter aortic valve
replacement. She is now referred for coronary angiography to evaluate for
ischemic heart disease as well as aortoiliac angiography to evaluate for
suitable iliac anatomy for large bore sheath for valve replacement. Ms.
Akridge was recently found to have acute-on-chronic kidney injury. Her renal
function has improved, but her estimated GFR is still 24.
PROCEDURE IN DETAIL: Informed consent was obtained. The patient was brought
to the catheterization laboratory in a fasting state. The right groin was
prepped and draped in sterile fashion. Lidocaine 1% was used for local
anesthesia. Fentanyl and Versed were used for moderate sedation. A 6-French
10 cm sheath was inserted into the right common femoral artery using a
modified Seldinger technique. Through this, a 6-French JL4 and JR4 catheters
were used for selective left and right coronary angiography. We then
exchanged the catheter for a 5-French Omniflush catheter which was advanced to
the distal abdominal aorta. Aortoiliac angiography was performed. In order
to get better sizing assessment of her iliacs, we exchanged the Omniflush
catheter for an IVUS catheter. We performed IVUS all the way from the left
common femoral artery to the left common iliac artery and then from to the
right common iliac artery to the right common femoral artery. At this point,
the catheter was removed. The arterial sheath was removed and hemostasis was
obtained via a Mynx device. There were no complications. Estimated blood
loss was 30 mL. Total contrast used was a total of 20 mL of Visipaque
contrast. We achieved this low contrast used using only selective pictures
with diluted contrast.
FINDINGS:
1. Left main is normal.
2. LAD is a large and tortuous vessel. There is a large first diagonal
branch with a 20% proximal stenosis.
3. Left circumflex is an angiographically tortuous vessel. It gives rise to
one medium sized obtuse marginal branch.
4. Right coronary artery is an angiographically dominant vessel. It is
tortuous in the mid to distal portion. There is a very small PDA. There is a
large posterolateral branch which is also very tortuous. There are only
luminal irregularities.
5. Aortoiliac angiography. There is no appreciable stenosis in the distal
abdominal aorta, bilateral common iliac arteries, bilateral external iliac
arteries, bilateral internal iliac arteries, and bilateral common femoral
arteries. There is no significant tortuosity in the iliac vessels.
6. IVUS arterial dimensions.
7. Left common iliac artery is 8.5 x 9.9 mm.
8. Left external iliac artery is 8.0 x 7.8 mm.
9. Left common femoral artery is 7 x 7.6 mm.
10. Right lower extremity: Right common iliac artery is 8.5 x 10 mm. Right
external iliac artery is 8.4 x 10 mm, right common femoral artery is 7.2 x
8.1 mm.
IMPRESSION:
1. Angiographically mild coronary artery disease.
2. Suitable iliac anatomy for transcatheter aortic valve replacement
Thanks,
Johnsonsr