DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS: Inferior wall ST segment elevation myocardial infarction.
POSTOPERATIVE DIAGNOSIS: Inferior wall ST segment elevation myocardial infarction.
1. Left heart catheterization.
2. Percutaneous coronary angiography via right femoral approach.
3. Percutaneous transluminal coronary angioplasty.
4. Implantation of a bare-metal stent.
1. Diagnostic catheterization: The right coronary artery is occluded at the level of AV groove. Multiple stents are seen, at least 3 are visualized in the right coronary artery; these stents are patent. No flow is present past the level of the AV groove. The left main coronary artery is normal. The circumflex coronary artery has a stent in the mid/distal vessel. This circumflex truck, however, is occluded after the level of a small septal perforator and it is occluded at the level of the stent. An obtuse marginal vessel is visible. High-grade lesion is present in the obtuse marginal. This is a small vessel of approximately 1.5 mm dimension. The lesion is a tapered lesion of about 95%. The area that was previously treated by Dr. Doe with stent implantation in the left anterior descending coronary artery is widely patent. Multiple stents are seen in the left anterior descending coronary artery and just past the stent, a 2.75 mm stent that was implanted by Dr. Doe, there is a small waist-like lesion of approximately 50%. There is a mismatch between the size of the stent and lumen of the vessel. There is a high-grade lesion distally in the left anterior descending coronary artery near the apex with 99% stenosis at that point. TIMI grade 3 flow is present to that lesion and TIMI grade 2 flow is present past that lesion. The diagonal subdivisional left anterior descending coronary artery has a high-grade ostial lesion of approximately 90%. TIMI grade 3 flow is present in the diagonal coronary artery.
2. Left ventriculogram was not performed.
3. Left ventricular end-diastolic pressures are significantly elevated at 30 mmHg.
DESCRIPTION OF PROCEDURE:
From the right femoral approach, a 6-French sheath was placed in the right femoral artery. Angiography confirmed AngioSeal placement for hemostasis postprocedure would be appropriate. A 6 French 4 cm left diagnostic catheter was used to obtain coronary angiograms of the left coronary system and then 6 French 4 cm Judkins right guide catheter was selected and passed as near coaxial manner as possible to the right coronary ostium. BMW guidewire was passed into the distal right coronary artery using the support of a 2.0 x 8 mm semi-compliant balloon. The wire passed easily through what appeared to be a fresh thrombus in the occluded area. The balloon was inflated multiple times to 16 atmospheres and withdrawn. This predilation angioplasty having been performed, there appeared to be a high-grade lesion at the level of the AV groove, which was 95% and quite short, approximately 6 mm in length. There was a poststenotic dilatation in the right coronary artery. A 2.75 x 8 mm Vision bare-metal stent was selected and passed over the wire and positioned carefully under fluoroscopic magnification views. It was inflated to a maximum of 14 atmospheres several times and the balloon carrier system was withdrawn. Excellent reformation of the lesion was achieved. All catheters and guidewires were removed after fluoroscopic visualization demonstrated no evidence of dye extravasation or other complications. An AngioSeal device was placed in the femoral artery and the patient returned to the room in stable condition having suffered no complications.
The patient with occluded right coronary artery, requiring percutaneous revascularization. Multiple stents are present, 2 in the left anterior descending, 1 in the circumflex coronary artery, and at least 3 in the right coronary artery. This patient has extensive disease and continues to smoke and may eventually require either maximal medical management alone or coronary bypass grafting.