PROCEDURE PERFORMED: Cardiac catheterization.
INDICATION FOR PROCEDURE: Unstable angina and abnormal stress test.
DETAILS OF PROCEDURE: The patient was taken to the cardiac catheterization lab and prepped and draped in the usual sterile fashion. The patient was sedated with Versed and fentanyl and the right groin was infiltrated with 2% lidocaine. A 5 French sheath was placed in the right common femoral artery. Judkins left 4, 3DRC and pigtail catheter as well as an Amplatz right modified catheter were used for the diagnostic portion of the procedure.
FINDINGS: The right coronary artery is a dominant vessel and gives off a couple of RV marginal branches that are severely, diffusely diseased and 100% occluded in its mid portion. There is a widely patent saphenous vein graft anastomosed to the posterior descending artery with good flow into the posterior descending and no significant disease seen distal to the anastomosis in the posterior descending.
The left main is relatively free of disease. It bifurcates into a nondominant circumflex and left anterior descending.
The circumflex gives off a high first marginal, which is a bifurcating vessel and is 100% occluded proximally. It fills faintly from left collaterals.
The second marginal is a moderate-sized branch with a 50% proximal stenosis and trivial disease elsewhere.
The AV groove vessel is 100% occluded.
There is a widely patent saphenous vein graft attached to the distal circumflex, just prior to it, giving a bifurcating posterolateral. Immediately distal to the anastomosis, the vessel is approximately a millimeter in caliber and there is a 90% stenosis just after the bifurcation of the obtuse marginal with the lateral branches. Neither of them supplies a very large territory. The larger of the two posterolaterals is the one with the lesion in it proximally. There is a significant mismatch between the size of the distal vessel with a poststenotic dilatation in the proximal vessel.
The left anterior descending wraps around the apex and bifurcates. There is a mid diagonal with a 99% proximal stenosis and an 80% stenosis in the left anterior descending. There is a widely patent saphenous vein graft attached to the diagonal with a proximal stenosis. It fills this diagonal well. The diagonal is a millimeter or less in caliber throughout its course.
There is a widely patent left internal mammary artery anastomosed to the mid left anterior descending. Approximately a centimeter or two distal to the anastomosis, there is 90% stenosis in the left anterior descending before it wraps around the apex and bifurcates distally and is a millimeter or less in caliber and diffusely diseased. Injection of the right groin revealed the sheath to be in the common femoral artery.
IMPRESSION: Severe native multivessel disease as described above with widely patent grafts as described above. There are several territories where the patient could be ischemic, including in the territory of the ungrafted 100% occluded first marginal, in the territory of the distal posterolateral after the anastomosis with the saphenous vein graft and in the territory of the distal left anterior descending where again the patient has disease after the anastomosis of the mammary. Her ischemia was in the inferior apex, likely in the territory where the patient’s distal left anterior descending lesion is; this is clearly not revascularizable. The patient could potentially have a posterolateral revascularized; however, not sure of the benefit. The patient still has several other ischemic territories and the ischemia was in a different distribution and this would be a high risk procedure for the patient. At this point, recommend medical management.
