DATE OF STUDY: MM/DD/YYYY
PROCEDURES PERFORMED:
1. Cardiac catheterization.
2. Percutaneous coronary intervention.
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in a sterile manner and locally anesthetized with 2% lidocaine to the right femoral artery area. JL4 and JR4 diagnostic catheters were used for the diagnostic portions of the procedure. All catheters were aspirated and flushed prior to their use. All catheters were advanced under fluoroscopic guidance over a guidewire and retracted over a guidewire.
A 6-French sheath was placed in a retrograde manner in the right femoral artery over a guidewire and it was aspirated and flushed. A JR4 catheter engaged the right coronary artery and injection revealed a normal right coronary artery with two stents in the mid aspect of the right coronary artery, which were widely patent. There were only minor luminal irregularities in the remaining right coronary artery circulation. The right posterior descending is small and unremarkable. The right posterolateral branch is unremarkable.
A JL4 catheter engaged the left main coronary artery. Injection revealed normal left main coronary artery. The left circumflex and its branches appeared to be angiographically unremarkable. The mid LAD beyond the first diagonal branch had a 40% diffuse stenosis, which was eccentric in nature. The LAD coursed around the apex of the left ventricle. The first diagonal branch had 80% proximal stenosis and 80% mid vessel stenosis. This first diagonal branch appeared to provide blood supply to a substantial portion of the lateral wall of the left ventricle.
It was elected to proceed with PCI. Angiomax was given per protocol. The patient was already receiving Plavix for the previously placed stents. The 5-French diagnostic catheter was exchanged for 6-French JL5 angioplasty guiding catheter. A 190 BMW guidewire was advanced beyond the serial 80% stenosis at the proximal and mid diagonal of the first diagonal branch coronary artery.
A 2.25 x 12 mm Voyager balloon was inflated into the distal 80% lesion to 8 atmospheres up to 25 seconds. TIMI III blood flow. There was some element of spasm at this wound site with a residual 60% stenosis. Then, the balloon was retracted to the proximal 80% stenosis and another inflation occurred to 9 atmospheres at the proximal lesion. This lasted for 25 seconds. The balloon was deflated. There is a residual 50% narrowing at that region.
Next, it was elected to stent the distal region first. Consideration was given to drug-eluting stent but was stopped at this portion of the mid distal artery, as it was smaller in caliber than that which would accommodate a drug-eluting stent. As a result, a 2.25 x 12 mm Mini-Vision stent was deployed in the distal 80% lesion with a residual 60% lesion after balloon angioplasty. This stent was deployed at 14 atmospheres x30 seconds. There was TIMI III blood flow at this site. There was no evidence of dissection at this site. There was no dye extravasation.
Next, a Cypher drug-eluting stent was placed proximally in the proximal diagonal 50% residual stenosis. A 2.5 x 13 Cypher drug-eluting stent was paced there and inflated to 12 atmospheres x40 seconds. There was TIMI III blood flow in the diagonal branch artery. The proximal lesion was reduced to 0% residual stenosis with no dissection or dye extravasation. All angioplasty hardware removed and the patient was in good condition at the close of the procedure.
CONCLUSIONS:
1. Patent right coronary artery stents previously placed. These stents were evaluated with diagnostic angiography because the patient re-presented with atrial fibrillation, which was converted with drugs.
2. Successful PTCA and stenting of two lesions in the first diagonal branch of the coronary artery with the distal lesion ultimately stented with a 2.25 x 12 mm Mini-Vision stent with 0% residual stenosis. The more proximal lesion was stented with a 2.5 x 13 Cypher drug-eluting stent with 0% residual stenosis at that site. It was noted that the patient has 40% narrowing, which is diffuse in the mid LAD.
PLAN:
1. A 30-minute infusion of Angiomax.
2. Plavix 300 mg will be given.
3. Antilipidemic agents will be increased with atorvastatin being increased to 80 mg upon discharge.
4. The patient will be hydrated and monitored on telemetry.
PROCEDURES PERFORMED:
1. Cardiac catheterization.
2. Percutaneous coronary intervention.
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in a sterile manner and locally anesthetized with 2% lidocaine to the right femoral artery area. JL4 and JR4 diagnostic catheters were used for the diagnostic portions of the procedure. All catheters were aspirated and flushed prior to their use. All catheters were advanced under fluoroscopic guidance over a guidewire and retracted over a guidewire.
A 6-French sheath was placed in a retrograde manner in the right femoral artery over a guidewire and it was aspirated and flushed. A JR4 catheter engaged the right coronary artery and injection revealed a normal right coronary artery with two stents in the mid aspect of the right coronary artery, which were widely patent. There were only minor luminal irregularities in the remaining right coronary artery circulation. The right posterior descending is small and unremarkable. The right posterolateral branch is unremarkable.
A JL4 catheter engaged the left main coronary artery. Injection revealed normal left main coronary artery. The left circumflex and its branches appeared to be angiographically unremarkable. The mid LAD beyond the first diagonal branch had a 40% diffuse stenosis, which was eccentric in nature. The LAD coursed around the apex of the left ventricle. The first diagonal branch had 80% proximal stenosis and 80% mid vessel stenosis. This first diagonal branch appeared to provide blood supply to a substantial portion of the lateral wall of the left ventricle.
It was elected to proceed with PCI. Angiomax was given per protocol. The patient was already receiving Plavix for the previously placed stents. The 5-French diagnostic catheter was exchanged for 6-French JL5 angioplasty guiding catheter. A 190 BMW guidewire was advanced beyond the serial 80% stenosis at the proximal and mid diagonal of the first diagonal branch coronary artery.
A 2.25 x 12 mm Voyager balloon was inflated into the distal 80% lesion to 8 atmospheres up to 25 seconds. TIMI III blood flow. There was some element of spasm at this wound site with a residual 60% stenosis. Then, the balloon was retracted to the proximal 80% stenosis and another inflation occurred to 9 atmospheres at the proximal lesion. This lasted for 25 seconds. The balloon was deflated. There is a residual 50% narrowing at that region.
Next, it was elected to stent the distal region first. Consideration was given to drug-eluting stent but was stopped at this portion of the mid distal artery, as it was smaller in caliber than that which would accommodate a drug-eluting stent. As a result, a 2.25 x 12 mm Mini-Vision stent was deployed in the distal 80% lesion with a residual 60% lesion after balloon angioplasty. This stent was deployed at 14 atmospheres x30 seconds. There was TIMI III blood flow at this site. There was no evidence of dissection at this site. There was no dye extravasation.
Next, a Cypher drug-eluting stent was placed proximally in the proximal diagonal 50% residual stenosis. A 2.5 x 13 Cypher drug-eluting stent was paced there and inflated to 12 atmospheres x40 seconds. There was TIMI III blood flow in the diagonal branch artery. The proximal lesion was reduced to 0% residual stenosis with no dissection or dye extravasation. All angioplasty hardware removed and the patient was in good condition at the close of the procedure.
CONCLUSIONS:
1. Patent right coronary artery stents previously placed. These stents were evaluated with diagnostic angiography because the patient re-presented with atrial fibrillation, which was converted with drugs.
2. Successful PTCA and stenting of two lesions in the first diagonal branch of the coronary artery with the distal lesion ultimately stented with a 2.25 x 12 mm Mini-Vision stent with 0% residual stenosis. The more proximal lesion was stented with a 2.5 x 13 Cypher drug-eluting stent with 0% residual stenosis at that site. It was noted that the patient has 40% narrowing, which is diffuse in the mid LAD.
PLAN:
1. A 30-minute infusion of Angiomax.
2. Plavix 300 mg will be given.
3. Antilipidemic agents will be increased with atorvastatin being increased to 80 mg upon discharge.
4. The patient will be hydrated and monitored on telemetry.
