Author + information
- Dhanan Umadevan1
Patient initials or identifier number
Relevant clinical history and physical exam
This is a 68 year old chronic smoker with underlying hyperlipidemia, gouty arthritis and hypertension. He had exertional chest pain, CCS class 2 for the last 2months. He also had dyspnea on exertion, NYHA class 2. He had no orthopnea or leg swelling. He had a strong family history of coronary artery disease. He had one admission to a peripheral hospital for angina.
On examination, he was alert with full GCS. His blood pressure was 120/80 with a heart rate of 60/minute. His cardiovascular examination was revealed normal heart sounds (1st and 2nd heart sounds) with an ejection systolic murmur at the aortic area which did not radiate to the ipsilateral carotid area. Respiratory examination revealed clear lungs with equal air entry. Abdominal examination was revealed soft abdomen with no organomegaly. His peripheral pulses were felt bilaterally. Reviews of other systems were normal.
Relevant test results prior to catheterization
An ECG in the clinic revealed sinus rhythm with normal axis. There was some T wave inversion inferiorly. An Echocardiogram showed normal LV cavity dimensions, ejection fraction of 46%, TAPSE 1.7, mild MR, mild TR, thickened aortic non coronary cusp and grade 1 diastolic dysfunction. He had a positive exercise stress test which showed ST segment depression in the inferolateral leads during recovery phase.
Relevant catheterization findings
The coronary angiogram was done via right femoral approach. Radial approach attempted but failed. There was difficulty in engaging the left coronary artery with a JL 3.5,6 French catheter. Therefore the right coronary was then engaged with a JR 4.0, French catheter. The angiogram revealed a chronic total occlusion of the right coronary artery with some intracoronary collateral. The left coronary artery was attempted again, this time using a Castillo 2 catheter. Only the Castillo 3 catheter could engage the left coronary artery. Angiogram revealed a chronic total occlusion of the left coronary artery at the ostial level. There was a tight stenosis in the mid left circumflex artery and proximal 2nd obtuse marginal branch. But alas the Castillo catheter could not be removed. A fluoroscopy shot of the external iliac area showed that the Castillo 3 catheter was kinked.
Attempts were made to untwist the catheter but to no avail. Then the left femoral artery was punctured and a 7 French, 35cm Arrow sheath was inserted due to the tortuosity of the left external iliac artery. A35mm snare which was loaded into a JL 4, 6 French catheters was used to snare the distal tip of the Castillo catheter. With the tip of the Castillo 3 catheter fixed, the catheter was able to be untwisted and removed. A cine study showed that there was a dissection of the right external iliac artery. A MPI catheter was advanced from the left side just proximal to the bifurcation of the abdominal aorta into the common iliac arteries. A Terumo wire was advanced across the dissection in the left external iliac artery into the right femoral artery. The Terumo wire was snared from the right femoral artery sheath and externalized. The MPI catheter was advanced across the dissection. The Terumo wire was exchanged with a Teflon wire. Cine shots were taken to ascertain the extension of the dissection in the right external iliac artery. A SMART Stent (10mm x 60mm) was deployed successfully. Post stenting, a small dissection distal to the stent was noted but it was left alone as it was not flow limiting.
Firstly try to obtain radial access if possible. Always use an Arrow Sheath if the Iliac arteries are very tortuous. If there is no 1:1 torque, suspect kinking of the catheter. If you are in trouble, ask for help early. Once in trouble, don’t panic, just think logically and solve the problem.