Pre- op Ox: CAD, CCS II chest pain, Abnormal stress test
Post-op Ox: Coronary artery disease

Procedures:
1. Selective left coronary angiography
2. Laser arthrectomy of the proximal and mid left anterior descending artery for 70-80% in-stent restenosis.
Pre procedure 70-80% in-stent restenosis with TIMI 3 flow. Post procedure less th an 50% in-stent restenosis with TIMI 3 flow.
3. Stenting of the proximal left anterior descending
artery for 80% disease with a 3.0 x 12 mm drug-eluting stent Onyx; pre procedure and 80% diseaseTIMI-3 flow.
Post procedure 0% disease with TIMl-3 flow
4. Angioplasty of the mid 70% occluded left anterior descending artery with a 2.25 x 12 mm balloon; pre procedure 70% disease TIMI- 3 flo w. Post procedure less than 50% disease TIMl-3 flow

Anesthesia: Lidocaine 2%

Access Site: Right femoral artery 6 French

Findings:
LMCA · mild disease
LCX · 60· 70 % m id left circumflex artery OMl · mild to moderate disease
LAD • 80% proximal disease prior to stent; 70-80% in-stent restenosis of the proximal-mid left anterior descending artery stent; 70% disease post stent
Dl – moderate disease

Procedure in detail :
The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed.
Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.

Right groin was anesthetized with lidocaine and a 6-French sheath was put into place percutaneously via guide-wire exchanger using ultrasound guidance and a micro puncture access kit. All catheters were passed using a Hipped guide* wire. Left system coronary angiography performed using a 6-French EBU3.5 catheter.

Intervention:
A 6 French EBU 3-1/2 guide was used to engage the left system. Once engaged, a run- through wire was placed distally down the left anterior descending artery. The laser catheter was then placed over the run-through wire and attempted to place inside the in-stent restenosis. Multiple attempts were made and the catheter was unable to enter the stent. The wire was pulled back and re-placed inside the stent as there was a concern that the wire may have gone behind the stent. The laser catheter was still unable to be advanced into the stent. A smaller laser catheter was exchanged and still unsuccessful in going inside the stent. After multiple attempts, the laser catheter was finally able to enter the stent and multiple runs were made. Post arthrectomy with laser, an angiogram was done showing less than 50% disease inside the stent. The laser catheter was removed and a 3.0 x 12 mm balloon was used to dilate the in-stent restenosis. Multiple different balloons were used without much improvement.
Given the inability to use the larger laser catheter, the
decision was made to leave the in-stent restenosis as it
is given TIMI -3 flow and less than 50% disease. The laser catheter was removed and an angiogram was done showing no perforations or dissections TIMI 3 flow. A 2.25 x 12 balloon was placed distally to the stent where there was 70%>
stenosis and that area was angioplastied. Post
Angioplasty, there appear to be less than 50% disease and no perforations or dissections TIMI 3 flow. The proximal portion prior to the stent in the LAD appeared to be significantly diseased and a 3.0 x 12 mm drug -eluting stent Onyx was placed. Post stenting, an angiogram was done showing no perforations or dissections and TIMI-3 flow. Heparin given during the entire procedure.

Closure Device: None

EBL: Less than 20 ml Complications: None Lines: None

Specimens: None Condition: Stable

Finding s:
Status post arthrectomy of the proximal to mid left anterior descending artery in-stent restenosis
Angioplasty of the mid left anterior descending artery after the stent
Stenting of the proximal left anterior descending artery with a
3.0 x 12 mm drug-eluting stent Onyx

Recommendation:
Continue with aspirin, Plavix, Lipitor therapy
Consider stage PC! for patients left circumflex artery as an outpatient