PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Selective coronary cineangiography of the right and left coronary arteries.
3. Selective angiography of the LIMA and saphenous vein graft.
DESCRIPTION OF PROCEDURE: The patient was brought to the cardiac catheterization lab. The right femoral area was prepped and draped in the usual sterile fashion. After anesthetizing the area with 2% lidocaine, a 5 French sheath was placed in the right femoral artery using Seldinger technique. Subsequently, selective coronary cineangiography of both the left and right coronaries was performed in multiple projections. This was performed using 5 French JR4 and JL4 diagnostic catheters. Left heart catheterization was performed but no left ventriculogram was performed in an effort to conserve contrast. This was performed using the 5 French JR4. Selective injection of the saphenous vein graft was performed using the JR4 diagnostic. Attempts were made to sub-selectively engage the LIMA graft with the JR4 diagnostic catheter, but we were unable to do this. It was selectively engaged with a 5 French LIMA diagnostic catheter. The patient tolerated the procedure well and no complications were encountered. The right femoral arterial sheath was removed and hemostasis was obtained using closure pad.
RESULTS/FINDINGS OF PROCEDURE:
HEMODYNAMICS: Left ventricular end diastolic pressure equals 10 to 12.
There was no significant gradient across the aortic valve by pullback post cineangiography.
LEFT VENTRICULOGRAM: No left ventriculogram was performed to conserve contrast.
LEFT MAIN: The left main had mild diffuse disease but no significant focal obstructive lesions.
LEFT ANTERIOR DESCENDING: The LAD coursed to and wrapped partially around the apex. There was competitive flow in the distal LAD from the LIMA graft. There is diffuse disease, especially in the mid vessel of the LAD. It appeared to approach 60% at the level of the diagonal branch. The diagonal branch itself had diffuse proximal disease with an area approaching 60% in the proximal diagonal branch.
LEFT CIRCUMFLEX: The circumflex had diffuse disease throughout. It gave rise to a small first marginal branch followed by a moderate sized second marginal branch. There were two areas of narrowing through the proximal portion of the marginal branch approaching 70 to 80% in each area. There was competitive flow from the graft distally. There was also retrograde filling of the radial T-graft through injection of the native coronary artery.
RIGHT CORONARY ARTERY: The right coronary artery is the dominant vessel. It gives off a moderate-sized bifurcating PDA. There is diffuse disease throughout the PDA, including in each bifurcation in the distal vessel. There is an area in the mid PDA approaching 60 to 70%. The distal posterolateral branch has diffuse disease with an area in the proximal portion approaching 50%. There is competitive flow in the distal portion of the posterolateral branch. There is diffuse disease throughout the body of the right coronary artery but no focal obstructive lesions.
SVG TO THE POSTEROLATERAL BRANCH OF THE RCA: This vein graft is widely patent. Anastomoses into a small bifurcating vessel.
LIMA TO THE LAD: The LIMA to the distal LAD is widely patent. There is brisk competitive flow with only mild filling of the distal LAD.
RADIAL T-GRAFT TO DIAGONAL/OBTUSE MARGINAL: There is diffuse disease throughout the entire radial T-graft. At the ostium of the radial T-graft, there is a 75 to 80% narrowing. This is diffusely diseased to the diagonal branch and the subsequent limb to the marginal branch is severely, diffusely diseased with multiple areas approaching 80%. As noted, it is diffusely diseased and of an extremely small caliber. There is actually relatively brisk competitive flow from the native vessels.
IMPRESSION:
1. Severe multivessel native coronary artery disease as described.
2. Widely patent vein graft to distal right coronary artery.
3. Widely patent left internal mammary artery to the left anterior descending.
4. Radial T-graft failure to obtuse marginal branch.
5. Recommend medical therapy.
