Case Study: 83 y/o male with asymptomatic abnormal carotid Doppler with progression of stenosis significantly over past year. RICA >90%, LICA 30-49%. On aspirin therapy

Past History/Risk factors: Diabetes

• TIA 4 years ago
• HTN
• Renal artery stenosis/Renal stent/Renal insufficiency (creatinine 1.7-2.0)
• No tobacco history
• Exercises daily (walks or rides bike)
• PVD (Right SFA atherectomy)

Carotid Angiogram revealed right internal ostial carotid stenosis of 90%. Left internal carotid artery unremarkable.

Diagnosis: Asymptomatic Carotid Artery Stenosis amenable to stent placement

Treatment: 2 days after angiogram after further hydration and stable creatinine the right internal carotid artery was dilated and stented using a distal protection device from 95%-0%.

Follow-up: Some balance issues 2 weeks post procedure related to hypoglycemia. No neurologic symptoms. CT of head without any abnormality. Creatinine remained at baseline. Carotid Doppler revealed widely patent stent in the right internal carotid artery.

Case Study:79 y/o male with AAA found on CT scan during work up for bladder cancer. Aneurysm was at the distal end of surgical repair site from AAA 1993. It was 8.5 cm in diameter. The CTA revealed amenable sizing for stent graft placement.

Angiogram: Distal aorta aneurysm starting below previously placed surgical graft. Neck of aneurysm 1 cm infrarenal. Severe angulation of both common iliac arteries. Aneurysm of left common iliac 2.7.

Past History/Risk Factors: AAA surgical repair 1993

• COPD-quit smoking5 years ago after 120 pack year history
• Rectal fistula/scrotal abscess-on keflex daily
• Bladder cancer-indwelling catheter-in remission
• Chronic atrial fibrillation-on coumadin
• Prostate cancer 1994

Diagnosis: AAA amenable to endovascular stent graft

Treatment: Admit to hospital 1 day prior to procedure for IV Vancomycin. Deployment of endovascular stent graft. Type I endoleak with aortic cuff deployed with no further evidence of endoleak.

Follow-up: KUB day following-good placement of AAA stent. Coumadin resumed. Ancef and Vancomycin continued 48 hours-no leukocytosis/fever. Discharged home without any complications.

Case Study: 63 y/o female with progressive dyspnea on exertion, different from shortness of breath from her COPD. Stress test revealed 1 mm ST depression in leads 2, 3, AVF, V5 and V6 with ischemia in the septum and global hypokinesis. Ejection Fraction 30%. Coronary angiogram results: severe anterior/inferior hypokinesis, EF 30%. Left Main angiographically unremarkable, LAD 85% lesion heavily calcified, Circumflex angiographically unremarkable, RCA proximal 50% lesion and mid 80% lesion heavily calcified.

Past History: COPD on nebulizer treatment and O2 at home

• Small cell lung cancer treated with radiation and chemotherapy
• Chronic renal insufficiency (creatinine values 1.6-2.6)
• HTN
• Hyperlipidemia
• PVD (fem-fem bypass on the right)

Risk factors for surgical intervention: COPD (severe) Lung Cancer (radiation/chemo)
Renal insufficiency, current tobacco use

Plan: Staged Coronary Intervention with LAD intervention first followed by RCA intervention.

Treatment: LAD treated by atherectomy/angioplasty and Drug Eluting Stent. Required lidocaine/levopohed/lopressor/ntg during procedure. LAD mid lesion 85%-0% with TIMI 3 flow at completion.

Post Procedure: Creatinine stable. Improvement in breathing symptoms/increase in ADL level/no smoking.

Stage II: One month later: RCA Intervention treated by atherctomy/angioplasty/Drug Eluting Stent. No additional meds than the routine meds. RCA mid 80%-0% with TIMI 3 flow at completion.

Post Procedure: Creatinine stable. Improved breathing.

Follow-up: Starting pulmonary rehab. Echocardiogram EF 35%. No dyspnea symptoms.

Case Study: 75 y/o female with recurrent TIA’s on coumadin therapy with a MRI revealing old infarcts in the right basal ganglia and paraventricular region and a new infarct in the right paraventricular region. Work up included a carotid doppler (RICA 50-69% and LICA 30-49%), stress test (negative for ischemia), echocardiogram with bubble study (no bubbles at rest but with valsalva a few bubbles crossed). TEE revealed at least 2 and possibly 3 PFO’s. The first PFO was in the typical location with a 1 cm tunnel length and a 2-3 mm PFO. The second was adjacent to the first and 2-3 mm in diameter. A third was seen more superior to the second. Aspirin was added to the coumadin regimen.

Diagnosis: Symptomatic PFO failing conventional drug therapy

Treatment: Successful deployment of a 35 mm Amplatzer device via transseptal technique covering 3 patent foramen ovales. Continued on coumadin/aspirin/plavix therapy until follow-up office visit.

Follow-up: 1 month later no neurological symptoms. Coumadin discontinued. Aspirin and Plavix continued. Echocardiogram revealed a negative bubble study.

46 y.o. male admitted through the ED with dull substernal chest pain x 1 hour. Troponin level was normal x 2. BP was hypertensive (160/110) and refractory to medication given in ED. He has a history of CAD with prior stenting of the RCA. He has been non-compliant with medical therapy and had been lost to follow-up. PMH: MI, hypercholesterolemia, hypertension, positive tobacco history, positive family history Diagnostic: CTA coronary performed urgently and demonstrated occluded stent. Treatment: BP medication Follow-up: Stress echocardiogram next day demonstrated resting hypokinesis of the apical anterior and basal inferior walls but no evidence of ischemia on post-stress images. Medication management.

52 y.o. male with known PVD, and experiencing LLE discomfort.

PMH/Risk Factors: PVD w/recent ABI demonstrating LLE <0.9 and RLE >0.9, bilateral mild/moderate carotid disease; CAD by cardiac catheterization/angiography in 2003 with normal nuclear stress test in June 2006; tobacco abuse with 74 pack year history; hyperlipidemia; hypertension

Diagnostic: CTA abdominal aorta w/run-off demonstrated 100% left common iliac w/unremarkable run-off, right LE w/mild disease and unremarkable run-off, aorta/mesentery/renal arteries unremarkable.

Treatment: PTA scheduled for 7/14/06

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