PROCEDURE NOTE
Informed consent was obtained after explaining the risks and benefits to the patient. Right wrist was draped and prepped in the sterile fashion. Allen’s test was performed in the right radial artery which was satisfactory. Patient was premedicated with 1.5 mg Versed and 50 mcg fentanyl IV. After injecting 2% lidocaine and the right wrist, right radial artery was accessed using micropuncture needle without difficulty. 4000 units of heparin, 200 µg nitroglycerin, 200 µg Cardene were given through radial sheath. 5 French Jacky catheter was used to cannulate left and right coronary arteries. Left ventricular end-diastolic pressure was measured. Patient was proceeded with intervention of right coronary artery. At the end of procedure, right axillary artery angiogram was performed as well as catheter pulled back to check gradient across the axillary artery stenosis. Patient remained hemodynamically stable and tolerated procedure well. Radial sheath was pulled and transradial band was applied with good hemostasis.

CORONARY ANGIOGRAM
1. Left main was large in caliber with mild ostial plaque. No significant disease noted.

2. Left anterior descending artery large in caliber region to the apex. Ostial and proximal LAD had 80% diffuse disease. Just before the stent there was 40% focal stenosis. Stents were noted in the mid LAD which were widely patent. Apical LAD was small in caliber but otherwise no significant disease in LAD.

3. Left circumflex artery was large in caliber and anatomically nondominant artery. Mild 20-30% diffuse disease was noted in the circumflex artery but overall circumflex artery was nonobstructive.

4. Right coronary artery was large in caliber and anatomically dominant artery. Right coronary artery was also calcified. Occipital and mid right coronary artery was also calcified. Proximal right coronary artery had a 30% eccentric stenosis. Mid right coronary artery had a diffuse mild atherosclerotic disease. Distal right coronary artery and a stent. There was 90% stenosis at the proximal edge of the stent. There was also 99% stenosis within distal stent. 2 lateral branch and posterior descending branches were patent with mild disease. Flow in the right coronary artery was TIMI-3 and normal.
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LEFT HEART CATHETERIZATION
Left ventricular end-diastolic pressure was 15 mmHg. No significant gradient across aortic valve.

PERCUTANEOUS INTERVENTION OF RIGHT CORONARY ARTERY
5 French JR4 guide catheter was advanced and right coronary artery was selectively cannulated. Angiomax was used for anticoagulation. 0.014 BMW guidewire was advanced distally in the right coronary artery. 0.014 water wire was advanced distally in the right coronary artery as a buddy wire for better support. 2.5 x 15 mm noncompliant balloon was advanced and distal right coronary artery lesion was predilated at 16 atm to 3 times. Nitroglycerin intracoronary was given. Subsequently 3.0 x 24 mm Promus premier drug-eluting stent was advanced but could not cross lesion within the previous stent due to significant calcified mid right coronary artery. Using same 2.5 x 50 mm balloon distal right coronary artery was predilated few more times. After few attempts 3.0 x 24 mm Promus premier drug-eluting stent was advanced the stent was deployed covering lesion within the previous stent at 15 atm. Stent was postdilated using 3.0 x 15 mm noncompliant balloon at 20 atm to 3 times. Nitroglycerin intracoronary was given. Subsequent angiogram revealed wide-open right coronary artery with a 0% residual stenosis, TIMI-3 antegrade flow and no evidence of dissection or perforation. Patient was hemodynamically stable and chest pain-free at the end of procedure.
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RIGHT AXILLARY ANGIOGRAM
Right axillary artery was calcified with 60-70% diffuse stenosis. There was also 20 mm gradient across the lesion.

IMPRESSION
1. Patent LAD stents
2. Nonobstructive left anterior descending and left circumflex artery
3. 99% in-stent restenosis of distal right coronary artery.
4. Successful percutaneous intervention and drug-eluting stent placement to distal right coronary artery.
5. 60-70% stenosis of right axillary artery.
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