Codes:
93458-26,59
76937-26
92928-LC
???

PRECATHETERIZATION DIAGNOSIS:
CAD.

POSTCATHETERIZATION DIAGNOSIS:
CAD. Right groin hematoma. No active bleeding at cath site in the right common femoral artery.

PROCEDURE PERFORMED:
Left heart catheterization, left ventriculography, selective coronary angiography via the right transfemoral approach.
US vascular access. Balloon angioplasty of the OM branch. Right common iliac and right common femoral
angiography. Balloon angioplasty of the right common femoral artery for bleeding.

CLINICAL FEATURES:
70 year old black female with DM, dyslipidemia underwent stenting of OM on 2-22-18 with a 2.25 x 16 mm Synergy
stent. Her Lexiscan on 9-20-18 suggested distal anterior wall stress ischemia. She underwent renal transplantation
years ago.
In view of of an abnormal myocardial perfusion stress test and known coronary artery disease having had
coronary stenting on 2/22/18, recommend cardiac catheterization to assess coronary status and to undertake
appropriate treatment.
The patient understands the nature, purpose, alternatives, benefits and risks of cardiac catheterization and
possible PCI, including but not limited to the effects of conscious sedation, myocardial infarction, emergency
cardiac surgery, bleeding, CVA, renal failure, compromised circulation in the extremities, and rarely fatal
complications and the patient offers an intelligent consent.

PROCEDURE:
After an informed consent was obtained, the procedure was undertaken via the right transfemoral approach. The right
groin was infiltrated with xylocaine and the right common femoral artery was entered and a sheath was placed in the
artery. Micropuncture technique was used with US vascular access. Left ventriculography and left coronary
arteriography were done using a JL 4 cm Judkins catheter. Right coronary arteriography was done using a 4 cm right
Judkins catheter.
Having noted instent restenosis in the OM branch, intervention was undertaken using a 3.75 cm EBU guiding
catheter, a Runthrough wire and balloon dilation was done using a 2.0 x 12 Emerge balloon catheter followed by
dilation with a 2.5 x 12 NC Quantum balloon and followed by 2.5 x 6 mm AngioSculpt scoring balloon with multiple
dilations. Having noted a satisfactory result, a AngioSeal was deployed. Sheath angiography was done at the
beginning of the procedure and it indicated no abnormality and the sheath insertion site was in the common femoral
artery. Care was taken to use an exchange wire because she had renal transplant on the right side. An AngioSeal
was deployed.
In the recovery room, it was noticed that she had a hematoma in the right groin. Manual pressure was appliedfor 20
minkute. During observation, she developed a vasovagal episode with hypotension which gradually improved.
To exclude significant bleeding, angiography was undertaken from the contralateral side.The left groin was infiltrated
with xylocaine and with US aid and using micropuncture technique, the left common femoral artery was entered. Using
Omnifush catheter and angled glide wire, the catheter was advanced into the left common iliac artery and contrast
injection was done. Subsequently angiography by hand injection of the iliac arteries and the right common femoral
artery was done. No evidence extravasation was noted. The right inferior epigastric artery was somewhat irregular but
no dissection or perforation was noted.
Balloon dilation of the right common femoral artery was done using a 6 x 60 mm Abbot’s Armada balloon which was
inflated for 3 minutes, just to tamponade any possible oozing that is not readily visible. The patient tolerated the
inflation well. Post dilation angiography was done. No evidence of perforation noted. No extravasation noted.The
patient was hemodynamically stable.

INTERPRETATION:
1. Hemodynamics: Please consult the hemodynamics data.
2. Left ventriculogram: Normal contractility with estimated EF at 60% The presence of a stent noted.
3. Coronary cine arteriogram:
A. Left main coronary artery: Stented vessel patent.
B. Left anterior descending artery: Free of significant disease.
C.Circumflex coronary artery: In-stent restenosis of the OM branch (90%) noted.
D. Right coronary artery:Free of significant disease.
4. Result of intervention:
The 90% instent restenosis in the OM branch was subjected to balloon angioplasty and AngioScult scoring balloon
angioplasty with a satisfactory result with minor residual narrowing. Since the branch is small, it was not deemed
prudent to deploy another stent in the vessel, crowding a small artery.
5. Angiography of the right pelvic arteries.
A. The right iliac arteries are patent. Evidence of kidney transplant noted.
B. The right common femoral artery was patent without obvious evidence of bleeding.Irregularity of the inferior
epigastric artery without perforation or dissection noted.
6. Balloon angioplasty of the right common femoral artery:
Balloon dilation was done to seal any possible oozing from the arterial puncture site.

FINAL DIAGNOSIS:
Normal LV function and in-stent restenosis in the OM branch with successful balloon angioplasty. She had right groin
hematoma and angiography showed normal right sided iliac arteries and femoral artery with no definite bleeding.
Balloon angioplasty of the right common femoral artery was done to seal any possible oozing which was not readily
apparent.