Case report
A 64-year-old woman, without prior cardiac history, was admitted to the
hospital with worsening dyspnea on exertion, orthopnea and swelling of
the lower limbs. She had hypercholesterolemia and prediabetes and was an
active smoker. Clinical examination showed signs of congestion. A
transthoracic echocardiogram revealed a dilated left ventricle with
severe left ventricular dysfunction, with a left ventricular ejection
fraction of 25%. The diagnosis of congestive heart failure was made.
Medical heart failure therapy was initiated.
To rule out underlying coronary artery disease, an invasive coronary
angiography was planned. However, vascular access could not be obtained
despite several attempts via different arterial access points, both
radial and femoral. A computed tomography angiography (CTA) as well as a
coronary computed tomography angiography (CCTA) were performed. The CTA
showed extensive peripheral artery disease, with a total occlusion of
the infrarenal aorta and both common iliac arteries (Leriche Syndrome),
a total occlusion of both subclavian arteries, and a critical stenosis
of the brachiocephalic artery (Figure 1), explaining the inability to
obtain access through conventional access sites. Furthermore, there was
a severe stenosis of the left internal carotid artery, and a mild
stenosis of the left common carotid artery. However, arterial access
could be obtained proximally at the left carotid artery. The CCTA showed
extensive coronary calcifications, with a severe stenosis in the LAD, a
moderate stenosis in the right coronary artery (RCA) and a moderate
stenosis in the left circumflex artery (LCx), and thus justified the
need for coronary artery revascularization.
After multidisciplinary Heart Team discussion, involving the vascular
surgeon, the decision was made to perform PCI of the LAD via the left
carotid artery.
The configuration of the catheterization lab was adjusted to enable
carotid access site preparation and PCI (Figure 2). The procedure was
performed under general anesthesia. First, the vascular surgeon made the
skin incision along the anterior border of the sternocleidomastoid
muscle. The subcutaneous tissue and platysma were incised. The sheath
over the common carotid artery was opened and the artery encircled with
a vessel loop. After that, a retrograde puncture of the artery was
performed and a guidewire with a 6 French sheath were positioned in the
aortic arch under fluoroscopy. To ensure that the sheath stayed fixated,
it was sutured to the sternocleidomastoid muscle (Figure 3). A
diagnostic coronary angiogram was then made by the interventional
cardiologist. The presence of a severe stenosis in the mid segment of
the LAD and moderate stenoses in the RCA and LCx were confirmed. PCI was
performed, with deployment of a XIENCE Sierraï›› 2.75 x 38 mm drug eluting
stent (Abbott, Santa Clara, CA, USA) in the mid LAD. Adequate stent
expansion and complete stent apposition were achieved, confirmed by
angiography and intravascular ultrasound (IVUS) (Figure 4). Finally, the
vascular surgeon removed the sheath, closed the puncture hole with a
prolene suture, and sutured the overlying tissues and skin.
The length of the combined procedure was 111 minutes, with a total
fluoroscopy time of 14 minutes. The total dose area product (DAP) was
25.311 Gy.cm2, with a total air kerma (K) of 318 mGy.
A total of 150 ml of iodinated contrast was used. During the procedure,
5000 units of unfractionated heparin were given. The patient received
dual antiplatelet therapy, consisting of acetylsalicylic acid 80mg and
clopidogrel 75mg once daily.
During the postoperative observation period, the patient showed good
vital signs, no chest pain and no neurological symptoms. She was
discharged from the hospital the next day.