PROCEDURES PERFORMED:
1. Diagnostic cardiac catheterization.
2. Selective cineangiography.
3. Selective injection of bypass grafts.
4. Percutaneous revascularization to the right coronary saphenous vein bypass graft.
OPERATOR: John Doe, MD
COMPLICATIONS: None.
PREOPERATIVE DIAGNOSES:
1. Unstable angina.
2. Remote coronary artery bypass graft surgery.
POSTOPERATIVE DIAGNOSES:
1. Ischemic cardiomyopathy.
2. Previous coronary artery bypass graft with failed grafts.
3. Successful revascularization to the right coronary saphenous vein bypass graft.
PROCEDURE MEDICATIONS: See nursing notes.
DETAILS OF PROCEDURE: Following routine sterile preparation of both groins, the right groin was anesthetized with 2% lidocaine for diagnostic cardiac catheterization and above procedures. The right femoral artery was then entered percutaneously and a 6 French arterial sheath placed.
An angled pigtail catheter was used to perform left ventricular pressure sampling and left ventriculography. The catheter was then withdrawn to assess for gradient.
Judkins left and right 4 diagnostic catheters were then used to perform a left and right coronary angiography. In addition, a Judkins right 4 diagnostic catheter was used to engage and inject the saphenous vein bypass grafts.
After completion of diagnostic angiography, it was decided to proceed with percutaneous revascularization of the right coronary saphenous vein bypass graft.
A multipurpose guide catheter was placed and a filter wire embolic protection device placed into the distal bypass graft. A 4 mm balloon was used to distally dilate the vessel followed by stenting with a 3.5 x 18 mm Cypher drug-eluting stent deployed at 18 atmospheres. Post dilatation was then performed with a 4 mm x 20 mm Quantum balloon. Excellent results were obtained with complete relief of the obstruction. The groin was then closed with a Perclose closure device at the end of the diagnostic cardiac catheterization and above procedures.
HEMODYNAMICS: LVEDP was 14. There was no significant valve gradient on pullback.
LEFT VENTRICULOGRAM: Left ventriculogram on biplane projection revealed globally depressed left ventricular systolic function, ejection fraction of about 40% to 45%. Segmental wall motion abnormality was noted with inferior wall dyskinesia. No mitral regurgitation was noted.
LEFT MAIN: There is 50% diffuse obstruction.
LAD: The LAD is a large vessel that extends around to the apex of the heart. There is a single large diagonal, which courses out to the anterolateral surface. The LAD has diffuse 70% proximal obstruction. The diagonal branch is filled in a competitive fashion by a patent bypass graft. In addition, there is retrograde filling into the LAD. In the diagonal distal to the vein graft insertion is a region of diffuse 80% obstruction with a small caliber vessel.
CIRCUMFLEX: The circumflex is nondominant, distributing as a pair of obtuse marginal branches. It is proximally obstructed as is its bypass graft and fills distally by left-to-left collaterals.
RIGHT CORONARY ARTERY: Dominant distributing as a posterior descending artery and posterolateral branch. The right coronary is proximally occluded. There is a patent vein graft inserting into the PDA branch. That bypass graft has an 80% proximal obstruction reduced to 0% with angioplasty and stenting.
IMPRESSION:
1. Globally depressed left ventricular systolic function; ejection fraction of 40% to 45%.
2. Inferior wall motion abnormality consistent with ischemia.
3. Multivessel coronary artery disease manifest as:
A. A 70% proximal LAD obstruction with competitive filling through a patent vein graft to the diagonal-one branch. There is retrograde filling of the LAD and 80% obstruction in the diagonal branch distal to the vein graft stenosis.
B. A 100% proximal circumflex occlusion with distal filling by collaterals and an occluded bypass graft.
C. Occluded right coronary artery in the proximal vessel with a patent vein graft with an 80% proximal obstruction.
4. Successful revascularization to the right coronary saphenous vein bypass graft utilizing angioplasty and stenting with a drug-eluting stent.
