9/3/17
PROCEDURE PERFORMED:
Left heart catheterization, left ventricular angiography in biplane projections,
selective right and left coronary angiography, saphenous vein graft
angiography x4, aortic root angiogram with PTCA, thrombectomy, installation
of intracoronary abciximab/ReoPro into a totally occluded thrombosed
saphenous vein graft, which probably goes to acute marginal branch from
the RCA.

CLINICAL DATA:
63-year-old female, history of 4-vessel coronary bypass
grafting surgery in 2010 at Saint Francis Hospital in Connecticut who
was awakened from a sound sleep with chest pain. EKG demonstrated ST-segment
elevation infarct, she was declared STEMI and transferred to the catheterization
lab.

The procedure was performed from the right groin using modified Seldinger
technique. I originally placed a 6-French catheter at the end of the
case. I up sized to a 7-French catheter, because patient was oozing
around the catheter. The patient had received 10,000 units of heparin
in the emergency room and received another 10,000 units of heparin with
incremental doses while in the cath lab. We had conscious sedation
with intravenous fentanyl and Versed, supervised by myself for approximately
an hour and a half.

HEMODYNAMIC DATA:
The patient is in a sinus rhythm with a heart rate of 55 to 65 throughout
this study. Arterial pressure 170/90, mean of 125, LV pressure of 170
with an LVEDP of approximately 20.

Left ventricular angiography: Left ventricular angiography was performed
after coronary angiography. We utilized a hand injection, because of
elevated end-diastolic pressure. In the RAO view, left ventricular
chamber size and systolic function appeared to be normal. There is
subtle hypokinesis of the inferior basal segment. Angiographic ejection
fraction estimated at 0.65 to 0.70. In the LAO projection, septal wall
motion is well preserved. There is an area of akinesis in the posterolateral
wall. No mitral regurgitation is seen.

Coronary angiography: Angiography is performed in multiple projections.

A. The right coronary artery appears to have been the dominant vessel,
severely and diffusely diseased, very small and totally occluded in
its proximal third.
B. The left main coronary artery is a very small vessel, there was a
50% distal left main lesion, appears to have ended in a bifurcation.
C. The native circumflex totally occluded at the left main.
D. The left anterior descending artery is very small. There is a proximal
lesion of about 40%. The LAD is totally occluded just after the origin
of the 1st septal perforator. There is also a small diagonal branch
noted.

Saphenous vein angiography is performed in multiple projections.
A. There are 2 grafts to the right coronary artery. The first graft,
which inserts into the right PDA appears to be an arterial conduit,
this is likely a LIMA and/or a RIMA, which is used as a free graft to
the distal PDA.
B. Saphenous vein graft, which appears to go to the RV marginal branch.
Although, we never saw the distal native vessel is totally occluded
likely with thrombus at the distal insertion site. We had competitive
flow in the midportion of the graft, we never saw the distal anastomotic
site. It should be noted that the native coronary arteries are severely
and diffusely diseased and are very small.
C. Saphenous vein graft to the left anterior descending artery selectively
visualized, the proximal anastomotic has a lesion of about 30% to 40%.
In the mid segment of the graft, there is a lesion of at least 80%.
Although, the graft is somewhat patulous. The diameter appears to
be about 1-1/2 mm at its narrowest. There is TIMI-3 flow. The distal
anastomotic site into the LAD appears to be patent and fills retrograde
back to a large diagonal branch and antegrade.
D. Saphenous vein graft to the circumflex branch is also degenerated.
The origin of the graft is patent. There is an eccentric lesion in
the midportion of the graft approaching 80% to 90% with diffuse disease
distally. The distal native circ is small and diffusely diseased.

Aortic root angiogram was performed, as I could not initially locate
the forth graft, which turned out to be occluded. The aortic root is
well opacified with dye. The valve is trileaflet. There is trivial
aortic insufficiency. We visualized 3 grafts coming off the aorta.

After identifying the culprit vessel, we elected to attempt intervention
although I was not confident that we would be successful. ACT was checked,
the patient was given another 5000 bolus of heparin and a 6-French RCB
guide was used to cannulate the native vessel. Control angiograms were
taken, demonstrating TIMI 0 flow into the distal portion. There was
competitive flow implying some collateral flow. We wired the vessel
as far as I could safely go with an 0.014 support wire. We used a 2
x 20 Emerge to do low-pressure angioplasty, multiple approximately 8
to 10 inflations of the balloon were performed in what I thought was
the distal right coronary artery for 30 seconds each, the diameter was
1.93 mm. Post angioplasty angiograms demonstrated no change in the
appearance of the vessel with TIMI 0 flow into the distal portion of
the vessel. At this point in time, we placed an export thrombectomy
catheter. We advanced it distally as far as safe and then thrombectomy
was performed. We removed multiple pieces of small old clot. Repeat
angiograms still demonstrated TIMI-0 flow into the distal right coronary
artery. At this point in time, I gave 10 mL of abciximab through the
export thrombectomy catheter directly into the mid portion of the graft
to the RCA. We observed the patient in the laboratory for approximately
15 minutes. No significant improvement in perfusion into this graft
was noted, I terminated the case at this point in time. Because of
oozing around the 6-French sheath, I upsized to a 7-French sheath.

IMPRESSIONS:
Unsuccessful attempt at opening a degenerated saphenous vein graft to
a right coronary artery.

COMMENTS:
This patient has well preserved LV function, but has severe vein graft
disease. She needs revascularization. Unfortunately, her long-term
prognosis is poor based on her diffuse atherosclerosis and noncompliance.
The patient needs to quit smoking. She will be loaded with Plavix
in the cath lab and aspirin, she needs to be on for life, she has stopped
taking her aspirin for some reason.

9/5/17
PROCEDURE PERFORMED:
Left heart catheterization, PCI, placement of 2 stents in a degenerated
saphenous vein graft to the circumflex system, PCI of a saphenous vein
graft to the left anterior descending artery with placement of 1 drug-eluting
stent in the LAD vein graft. Procedure complicated by distal embolization
and no/slow reflow secondary to grumous material in the graft. An intra-aortic
balloon pump was placed. CODE BLUE was called. The patient was intubated
in the cath lab. Prognosis is poor.

CLINICAL DATA:
The patient is a 63-year-old female, originally admitted early Monday
morning with a STEMI. She had closed a degenerated saphenous vein graft
to acute marginal branch of the right coronary artery. We were able
to wire the vessel. We were unable to re-establish flow. At the time
of her original cardiac catheterization, she was found to have severe
diseased and degenerated vein grafts in the circumflex and in the LAD.
LV function was surprisingly good.

DESCRIPTION OF PROCEDURE:
After informed consent and the patient did note this was a high-risk
procedure, the patient was brought to the cath lab. Right groin sterilely
prepped and draped in usual manner, infiltrated with 2% lidocaine.
Using modified Seldinger technique, a 6-French arterial sheath was placed.
Our peripheral IV apparently had malfunctioned and I placed a 5-French
venous sheath in the right common femoral vein. We selected an LCB
catheter, which gave poor backup. I changed to a multipurpose guiding
catheter. Control angiograms of this circumflex were taken. The patient
was bolused with Angiomax and a drip was begun. The patient had multiple
doses of fentanyl and Versed for conscious sedation for approximately
3 hours. We engaged the graft first with an LCB catheter, which gave
poor backup. We changed to a multipurpose catheter, which gave adequate
backup. We decided to directly stent the graft to the circumflex.
The first stent was a 4 x 18 in Medtronic Resolute drug-eluting stent.
This was positioned in the midportion of the graft and deployed using
gradually increasing pressures to 19 atmospheres. The MLD was 4.2 mm.
Repeat angiograms demonstrated an acceptable angiographic result.
We then elected to stent the distal portion of the graft with a 3.5
x 30 Medtronic Resolute drug-eluting stent. This stent was deployed
at 9 atmospheres for 60 seconds, yielding a 3.5 MLD. Repeat angiograms
demonstrated good positioning. It was apparent that the proximal portion
of the stent was under deployed. I then selected a 4.5 x 20 NC Emerge.
We did a single inflation at 8 atmospheres for 30 seconds, yielding
a 4.4 MLD in the proximal portion of the stent. Final angiograms were
taken with and without the wire, demonstrating an acceptable angiographic
result with TIMI-3 flow into the vessel. At this point in time, we
elected to intervene upon the LAD. We utilized the same multipurpose
guiding catheter. Control angiograms were taken, demonstrating severe
disease in the mid graft with moderate disease in the proximal graft.
We pre-dilated the lesions in the LAD graft with a 3.5 x 30 Emerge
Monorail. There was evidence of a dissection in the mid lesion. I
then elected to stent this. We placed a 4 x 34 Resolute stent, which
was deployed at 14 atmospheres for 60 seconds, yielding a 4.25 MLD.
Repeat angiograms demonstrated no flow. At this point in time, we
placed a 3.5 x 30 mm angioplasty balloon dilating the whole graft.
The patient became hemodynamically unstable at this point in time.
I placed an intra-aortic balloon pump. A CODE BLUE was called. The
patient was intubated by Anesthesia. Repeat angiograms demonstrated
TIMI 2 flow into the native LAD. Dr. H. was present and I reviewed
the films with him. It was obvious this was thromboemboli from grumous
material in the degenerated saphenous vein graft and that surgery would
probably not improve the patient’s chances of recovery. At this point
in time, we ordered ReoPro. I gave the ReoPro bolus of 20 mL directly
into the saphenous vein graft to the left anterior descending artery.
I had also given several-100 mcg of intracoronary nitroglycerin directly
into the vein graft. At this point in time, the patient’s hemodynamics
were relatively stable. She had one run of wide QRS tachycardia, rate
of approximately 150, which may have represented a reperfusion arrhythmia.
We were prepared to cardiovert her, however, blood pressure remained
adequate and she spontaneously converted back to a sinus rhythm. She
had persistent ST-segment elevation in the anterior leads when she did
leave the lab. The balloon pump was set at 1:1. She was started on
amiodarone drip and transferred to the CVICU in critical condition.
Again, prognosis is poor at this point in time.

IMPRESSION:
1. Successful stenting of a saphenous vein graft to the circumflex.
2. Successful stenting of a saphenous vein graft to the LAD. unfortunately,
procedure was complicated by no reflow secondary to emboli of grumous
material in the saphenous vein graft.

As noted above, the patient was hemodynamically unstable. CPR was begun.
CODE BLUE was called. Intra-aortic balloon pump was inserted and the
patient was intubated and started on pressors and transferred to the
ICU in critical condition.