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Patient initials or identifier number
Relevant clinical history and physical exam
He was admitted to my hospital because of angina at rest since 16 hours, he has problem chest pain since 6 months and gradual increasing if light-moderate activity. He was sometimes dizziness; Risk factor is dyslipidemia, diabetes mellitus and hypertension. History was sequel stroke and TIA. Physical examination, X Ray thorax, laboratorium were normal.
Relevant test results prior to catheterization
Echocardiography showed EF 55% and no regional wall motion abnormality. Carotid Doppler was significant stenosis 90% right internal carotid. He have unstable angina and history stroke that concomitant severe coronary and carotid artery disease.
Relevant catheterization findings
Baseline Coronary and Carotid Angiography. That found coronary angiography was coronary artery disease 3 vessel disease (mid RCA 75% and distal RCA 60%, proximal LCx 60% and mid LCx 90%, ostial LAD 75% and mid LAD 40%). That coronary angiography was three vessels disease with syntax score 26 and carotid angiography was stenosis 90% right internal carotid artery and stenosis 30-40% left internal carotid. We planned first carotid plasty.
Procedure carotid plasty sheath inserted 7Fr into right femoral artery. Therefore, guide wire (GW) Terumo puton right externa carotid artery (Rt ECA) with guide catheter (GC) 3.5JR 6Fron right common carotid artery (Rt CCA) Pushed GC JR to Rt ECA and alsorewiring terumo to amplantz stiff wire, so amplantz stiff wire put in mid ordistal Rt ECA. Cine shows step true position. Remove out GC JR from RtECA and insert, put long sheet 7Fr that connect with Y Connector in mid or distalRt CCA. Insertion coronary Wire (All Star) pass and across lesion Rt ICA andput up lesion’s or Rt ICA C3/C4. Insertion Protection Emboli Device (PED)spider over the coronary wire (All star) and put 10 mm up from lesion’s but before Rt ICA C3/C4. Protection Emboli Device deployed upfrom lesion rt ICA. Cine again showed step true position. Remove outcoronary wire (All star) and only PED deploying. The procedure continue topredilatation with balloon PTA 3.5 x 20 mm and pressure 14 atm. Continuinginsert stent, measured stent, put stent and across lesion Rt ICA by guidingcine. The Stent Carotis use accure link 5 x 30 mm. Deployed stent carotid havestill residual stenosis, so doing post dilatation with ballon 5.0 x 20 mm withpressure 8 atm. Cine again were showed no complication and residual stenosis.Continuing to remove out PED from Rt ICA. During procedure given heparin 5000IU (Target ACT 250-300) and atropine 1 mg pre procedural.
Many guidelines showed stroke during periprocedural CABG. One of caused is carotid artery stenosis. The patient has coronary and carotid artery disease with symptomatic that will be increasing 4 times stroke. The patient is often unilateral and asymptomatic that need revascularization. Many data journals & showed controversy management concomitant severe carotid artery stenosis and coronary artery disease. Carotid artery stenting or carotid endarterectomy that similar safety stroke or death or myocardial infarction between stenting or carotid endarterectomy in-patient CABG. Patient intra and after procedural carotid stenting were no have complication. After stenting carotid, He will do PCI.