PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Left ventricular angiography.
3. Aortic root angiography.
4. Right and left coronary angiography.
5. Saphenous vein graft angiography x3.
6. Left internal mammary angiography.
7. Left subclavian angiography.
8. Abdominal aortogram with selective left common iliac angiogram
and monitored anesthesia care for 1 hour.

CLINICAL DATA:
69-year-old female with severe peripheral vascular disease,
kyphoscoliosis, post Harrington rod procedure who has severe coronary
artery disease, abnormal stress test performed recently demonstrating
multiple reversible perfusion defects and depressed ejection fraction.
Procedure was performed from the right groin using modified Seldinger
technique. There was severe disease in the right common iliac artery.
We utilized a 25-cm 6-French sheath, because of tortuosity, 6-French
diagnostic catheters were utilized.

HEMODYNAMIC DATA:
The patient is in sinus rhythm with a heart rate of 60 to 70 throughout
the procedure. The arterial pressure 180/60 and 104 mean. LV pressure
of 180 with an LVEDP of 12 to 14, there was a 20 mm gradient on pullback
across the right common iliac lesion in the proximal, but not ostial
portion of the common iliac artery on the right side.

Left ventricular angiography was performed in a single RAO projection.
Left ventricle is well opacified with dye, it is moderately dilated.
There is severe hypokinesis of the inferior basal segment. There is
severe hypokinesis in the anterior lateral wall, apical wall motion
is relatively well preserved. The mid inferior wall is hyperkinetic.
Angiographic ejection fraction is estimated in the 35% range. There
was no mitral regurgitation.

Her aortic root angiogram, aortic root angiogram was performed in a steep
LAO projection. The aortic root is aneurysmal and moderately dilated,
appears to be at least 5 cm. There was moderate/2+ aortic insufficiency.
There are buttons for 3 saphenous vein grafts. All saphenous vein
grafts appeared to be closed. Saphenous vein graft, which appears to
have gone to an intermediate or diagonal branch has multiple stents
in it. No flow is noted through these. There is no evidence of dissection.

CORONARY ANGIOGRAPHY:
Coronary angiography is performed in multiple projections.

A. The right coronary artery appears to have been a dominant vessel.
It is totally occluded in its proximal portion. Right after a large
right ventricular marginal branch arises. There are intercoronary collaterals
to the distal right coronary artery; however, we cannot visualize the
PDA or posterior lateral branches. There were also intracoronary collaterals
from the left circumflex.
B. The left main coronary artery is a moderate type vessel arising from
the left cusp. There appears to be mild ostial left main lesion approximately
20%, which is nonobstructive to flow. The left main ends in a bifurcation.
C. The circumflex is a large, but nondominant vessel. There is mild
atherosclerotic plaque in the proximal circumflex. It gives rise to
a series of small high lateral branches before giving rise to the groove
branch. It is tortuous in this segment. There appears to be severe
disease in the AV groove branch. As the circumflex continues, it bifurcates
into medium posterior and marginal branches. There is a saphenous vein
graft, which is inserted right at this bifurcation. The vein graft
is closed. There appears to have been a lesion here. There was brisk
flow. No significant obstructive disease is noted. The circumflex
provides a profuse collateral flow to the distal right coronary artery
and also to the diagonal system of the left anterior descending artery.
D. The left anterior descending artery has flush total occlusion at
its ostium. No significant antegrade flow was noted.

Saphenous vein graft angiography is performed x3. Vein graft to the
RCA closed. Vein graft to the circ marginal closed. Stented vein graft
to an intermediate or diagonal branches closed with no flow.

Left subclavian angiogram is performed. The left subclavian is patent.
There was severe calcific disease noted. The left internal mammary,
we cannot see the ostium of it, but the vessel appears to be free of
significant obstructive disease, inserts in end-to-side manner in the
mid to distal third of the LAD. The distal insertion sites widely patent
with brisk TIMI-3 flow into the LAD.

Abdominal aortogram is performed in a single AP projection. The exam
is somewhat limited due to hardware from previous spinal surgery. The
celiac axis is patent. Superior mesenteric and inferior mesenteric
arteries are patent. There are profuse abundant pelvic collaterals
noted. There is severe obstructive disease in the right iliac artery
indeed we had problem crossing this and required a Wooley wire and a
long sheath to complete cardiac catheterization. There was an 80% obstruction
in the proximal right common iliac artery. Unable to evaluate the left
common iliac artery, because of hardware. The left renal artery has
a lesion of approximately 40% to 50% at its ostium. The right renal
artery is patent. However, again because of hardware and anatomy unable
to judge whether there is any significant disease.

IMPRESSIONS:
1. Dilated cardiomyopathy ejection fraction 35% with multiple wall
motion abnormalities.
2. Moderate aortic insufficiency.
3. Ascending aortic aneurysm.
4. Severe coronary artery disease including a totally occluded LAD
and right coronary arteries. There is mild disease in the ostial left
main, with a patent circumflex.
5. Total occlusion of 3 saphenous vein grafts.
6. Patent LIMA graft to LAD.
7. Peripheral vascular disease with a high-grade lesion in the right
common iliac artery with mild disease in the left renal artery.
8. Diffuse, but nonobstructive disease in the distal abdominal aorta.

COMMENTS:
This patient has dilated cardiomyopathy. The right coronary artery and
graft are totally occluded. The patient has abundant coronary collaterals,
which appears to be a poor candidate for redo coronary bypass grafting
operation. She may benefit from revascularization of the right iliac
artery. At this point in time, maximal medical therapy will be instituted.
The patient needs aggressive treatment of her dyslipidemia.