Cardiac Catheterization Study – 11/27/2023

Transradial Angioplasty

Pre-operative diagnosis:
Inferior ST elevation and anterior ST changes

Post-procedure diagnosis:
One vessel coronary artery disease s/p mechanical aspiration thrombectomy and PCI to the proximal to mid LAD with IVUS guidance with overlapping DES x 2

Performed by:
Chirag Chauhan, MD MS

Procedure details:
PROCEDURES PERFORMED:

1. Right radial artery access using micropuncture needle
2. Selective right and left coronary angiography
3. Left heart cath
4. Mechanical aspiration thrombectomy to the left anterior descending coronary artery
5. Intravascular ultrasound of the left anterior descending coronary artery
6. Percutaneous coronary intervention of the proximal to mid with two DES
7. VascBand to the right radial artery for hemostasis

INDICATION FOR PROCEDURE:
43-year-old with a past medical history significant for common variable immunedeficiency, persistent mastoiditis status post multiple surgeries, Lyme dis
ease,and DVTs/saddle PEs who presents to the Swedish Medical Center ED with complaints of 3 days of shortness of breath, diaphoresis, fever up to 103F,
chest pain/pressure, and left shoulder pain. EKG was performed in the ED which revealed acute inferior ST elevation with Q waves along with possible mild
anterior ST elevations with continued chest pain for which a cardiac alert was called. Presents for coronary angiography and possible PCI.

MEDICATIONS:

1. Versed 2mg IV
2. Fentanyl 100mcg IV
3. Lidocaine 2cc 2%
4. Verapamil 2.5mg IA
5. Nitroglycerin 200mcg IA
6. Heparin 8,000 units
7. Nitroglycin 500mcg IC
8. Brillinta 180mg once
9. Integrilin bolus and drip

MODERATE SEDATION:
Moderate sedation provided with Versed and fentanyl as above. This was initiated at 1015p and the procedure concluded at 1104p for a total 51min of monitoring.

PROCEDURAL DESCRIPTION:
Verbal informed consent was obtained due to the emergency of the procedure. Risks and benefits discussed with the patient. He was brought to the cardiac catheterization laboratory. The right wrist area was cleaned, prepped, and draped in the usual sterile fashion. The right wrist was infiltrated with lidocaine for local anesthesia. He was also given moderate sedation as above. Using a modified Seldinger technique with a micropuncture needle and ultrasound guidance, the right radial artery was accessed. Images were stored and the vessel was confirmed patent.

A 6-French slender Terumo sheath was introduced into the right radial artery. This was subsequently flushed with nitroglycerin and verapamil to help prevent radial vasospasm. A 5 French JL3.5 diagnostic catheter was advanced into the aortic root. The catheter was used to selectively engage the left main coronary artery. Selective left coronary angiography was performed the usual views. The catheter was exchanged out for a 5 French JR4 diagnostic catheter which was placed into the LV over a wire. LV pressure was measured and pullback was performed across the aortic valve. The catheter was then used to select engage the right coronary artery, selective right coronary angiography was performed in the usual views. The catheter was then removed from the aortic root over the exchange length wire. Heparin was provided as a procedural anticoagulant as we decided to proceed with percutaneous coronary intervention.

A 6 French EBU 3.5 guide catheter was placed into the left main coronary artery. Run-through wire was placed across the lesion to the distal LAD. Next, mechanical aspiration thrombectomy was performed with a CAT Rx catheter using the penumbra system both antegrade and retrograde fashion. Following this an Eagle eye platinum IVUS catheter was placed into the vessel in both an antegrade and retrograde fashion IVUS was performed which revealed significant thrombus and plaque rupture in the proximal to mid LAD. There was also some concern for possible coronary vasospasm versus dissection, this did not improve with nitroglycerin IC. IVUS did confirm an area of small dissection which could have been secondary to the penumbra catheter just past the region of plaque. The catheter was removed intact.

Following this the decision was made to proceed with stenting. Due to thrombus and concern for possible dissection, we decided to direct stent the area. An Onyx frontier 4.0 x 38 mm stent was chosen and placed from the proximal LAD to the mid segment. The stent was deployed at 12 atm for 12 seconds. And the stent balloon was removed intact. We then decided to stent the region just after this as there was residual area of dissection noted. Ultimately, A resolute Onyx 3.5 x 26 mm stent was chosen and placed overlapping the proximal stent across the lesion from. The stent was deployed at 12 atm for 10 seconds.

There was some decreased blood flow distally thus nitroglycerin was given intracoronary at that time. The stent balloon was removed intact. Next, the intravascular sound catheter was placed back into the vessel. Both an antegrade and retrograde fashion IVUS was performed which revealed good stent apposition distally and in the midportion. There was some mild apposition of the proximal segment. Next an NC Euphora 4.5 x 12 mm balloon was chosen and placed in the proximal portion of the stent. This was inflated to 16 atm for 10 seconds. Nitroglycerin was then again given after the stent balloon was removed intact. There is no signs of dissection or perforation. There was some residual thrombusand occlusion of the distal LAD vessel. Decision was made to proceed with Integrilin bolus x 1 and a drip. The guidewire subsequent removed and final angiogram revealed an adequate result.

After all wires and catheters were removed, a VascBand was applied to the right radial artery to obtain adequate hemostasis. The patient tolerated the procedure well. He was transferred to the ICU in stable condition.

Findings:
HEMODYNAMICS:
Left heart cath:
LV: 139/-2, 23
AO: 129/87 (105)

• No significant gradient

CORONARY ANGIOGRAPHY:
Dominance: Right

Left main: Large-caliber vessel without significant disease giving rise to the left anterior descending coronary artery and the left circumflex coronary artery.

Left anterior descending: Very large caliber vessel proximally that gives rise to a high rising first diagonal branch that bifurcates. This diagonal branch has luminal irregularities but no other distinct stenoses. Just before the diagonal, the LAD tapers with a 30-40% stenosis and tapers down to a 80-90% just after the diagonal. There is an area of thrombus noted with a large round thrombus in the midportion of the LAD with TIMI II flow to the distal vessel.

The distal LAD has some staining concerning for thrombus downstream into wraparound portion of the LAD which is likely the cause of the ST elevations inferiorly. The distal vessel of the LAD has luminal irregularities.

Left circumflex: Very large caliber vessel that is nondominant. This gives rise to the very small first OM and a very small second OM branch followed by a small OM 3, a moderate OM 4, and a large OM 5 branch which bifurcates. Each of the OM branches have only luminal irregularities noted. The AV groove left circum flex comes off after the OM 5 branch. Between the OM 4 and OM 5 branch, there i sa 20-30% stenosis in the distal left circumflex vessel. No other distinct stenoses noted.

Right coronary artery: Large-caliber vessel proximally that has mild disease, up to 20% in the proximal segment followed by mild plaquing up to 30% in the mid segment and mild disease up to 10-20% in the distal segment before giving off the right PDA and PLV branches distally. There are some luminal irregularities in these distal branches but there is TIMI-3 flow to the distal vessel noted.

PERCUTANEOUS CORONARY INTERVENTION:
Lesion #1: Successful mechanical aspiration thrombectomy and percutaneous coronary intervention of the proximal to mid LAD with overlapping Onyx Frontier 4.0 x 38 mm and 3.5 x 26 millimeters drug-eluting stents postdilated to 4.7mm proximally with IVUS guidance.
Pre-: Lesion length 60 mm, stenosis 90%, TIMI-2 flow
Post-: Lesion length 0 mm, stenosis 0%, TIMI-3 flow

FLUORO TIME: 10.3 min
CONTRAST VOLUME: 180 cc of Isovue-370

SUMMARY:

1. Plaque rupture in the mid LAD with a 90% stenosis treated with successfulmechanical aspiration thrombectomy and percutaneous coronary intervention of the proximal to mid LAD with overlapping Onyx frontier 4.0 x 38 mm and 3.5 x 26mm drug-eluting stent postdilated to 4.7 mm proximally with IVUS guidance.
2. Otherwise, mild nonobstructive coronary disease in the rest of the LAD, left circumflex, and right coronary arteries and a right dominant system
3. Elevated left heart filling pressures and LVEDP of 23 mmHg
4. VascBand applied to the right radial artery for hemostasis.

RECOMMENDATIONS:

1. The patient will be transferred to the ICU for further monitoring and care and removal VascBand from the right radial.
2. Will continue patient on Integrilin for distal thrombus of the LAD for 12 hours after receiving bolus in the Cath Lab due to distal thrombus in the wrap around portion of the LAD
3. Will continue aspirin 81 mg daily and Brilinta 90 mg twice daily for atleast 1 year post PCI
4. We will start high intensity statin therapy tonight and monitor lipid panel in the morning tomorrow
5. We will check hemoglobin A1c and continue aggressive risk factor modificationfor coronary artery disease
6. Will continue patient on telemetry to monitor for any arrhythmias
7. Will continue antibiotics and follow-up on blood cultures with historyof CVID and recurrent/chronic infections. Will have low threshold to consult infectious disease as he follows as an outpatient.

Complications: none
Anesthesia type: local, moderate sedation
Estimated blood loss in ml’s: 20