Case Title

60 yr. Old man with a History of Multiple Coronary Grafts

Case History

This 60 yr. Old fine gentleman had received bypass surgery 6 years ago. He received 3 grafts. Venous graft to OM1, Venous graft to RCA and Internal Mammary graft to LAD. He was subjected to angiography for his severe angina. Angiography showed the Venous graft to OM1 was patent, graft to RCA was blocked but native RCA showed 90% stenosis distal to a stent in RCA. Stent was deployed in the RCA 2 yrs ago. While trying to enter the left subclavian, it was realized that there was a total occlusion of the left subclavian, right at its origin. The contrast injection into the right Vertebral artery opacified the left vertebral through the Circle of Willis. The left vertebral filled up the left subclavian artery.

1. To address the native RCA with suitable stent
2. To address chronic total occlusion of the subclavian artery.

His angina was largely explained by the lack of blood flow in his internal mammary artery due to subclavian block.

RCA was opened up with balloon and a 32 mm Taxus stent was deployed.

Total occlusion in subclavian artery was almost 20 mm long. There was no nipple and it was almost flush with aorta. Few bridging collaterals were seen. Lesion was crossed with great difficulty using right Judkins guide catheter and series of wires in succession. Ultimately, Miracle 6 gms. wire was successful. Lesion was opened up with 25mm long / 2mm Maverick2 Balloon. At this stage, Miracle wire was replaced by a double length 0.014 Stabilizer plus wire. Lesion was further dilated with a 3 mm Balloon.

The lesion was stented with Genesis 18mm / 7mm stent deployed directly into the lesion. This had to be done because the stent shaft was only 80 cms. long whereas the guide catheter was 100 cms. long.

In order to check correct placement with injections of contrast medium, 6F right coronary catheter was advanced from contra lateral groin and positioned near the mouth of left subclavian artery. The stent was deployed at 8 ATM. The final result was very good.

Kindly note the first 1-5mm of ostium is uncovered with the stent. The correct length of the needed stent was 20mm. Unfortunately it was not available at the time of treatment. This may expose the patient to somewhat increased risk of restenosis.

His angina was largely explained by the lack of blood flow in his internal mammary artery due to subclavian block. Right coronary diffused and critical stenosis in its mid-segment. Balloon dilatation with 2/20mm long Maverick 2 balloon. 2.25/32 Taxus Express stent. Shows Right coronary catheter at the ostium of Left Subclavian artery. Contrast injection shows few bridging Collaterals and totally occluded Subclavian Artery right at the ostium. Shows Miracle wire (6gms) entering one of the bridging collaterals. After some manipulation wire enters correct channel of totally occluded Left Subclavian artery. Wire positioned in the Left brachial artery. 2mm Maverick 2 balloon across the lesion. Kindly note that Miracle wire is replaced by 0.014" Stabilizer Plus wire. Successive dilatations of the totally occluded segment with using sequentially large balloons. Note: Genesis stent 18mm/7mm directly advanced over the wire without the guide support. Note: 6F guide catheter introduced fron the Left Femoral artery for contrast injection. Also note widely patent Left Internal Mammary Artery. Shows fully expanded stent insitu. Vertebral artery shows mild narrowing at the ostium. Aoratic root injection shows excellent stent results however first 1mm or 2mm of ostium is missed out.

Courtesy

Dr. A.B. Mehta
Director Of Cardiology,
Jaslok Hospital,
Mumbai, India.

Website: http://www.drabmehta.com
Email: drabmehta@cardiovalens.com