28120581 Visualization

This 73 Age - year Age - old Age female Sex , with a history History of History coronary History artery History disease History and situs History inversus History , had recently noticed left Biological_structure arm Biological_structure exercise Detailed_description weakness Sign_symptom .
The magnetic Diagnostic_procedure resonance Diagnostic_procedure angiogram Diagnostic_procedure and computer Diagnostic_procedure tomography Diagnostic_procedure of the upper Biological_structure limb Biological_structure vessels Biological_structure showed critical Severity stenosis Sign_symptom of the left Biological_structure - side Biological_structure SCA Biological_structure with calcification Sign_symptom near the orifice Biological_structure (Fig.1).
Percutaneous Detailed_description revascularization Therapeutic_procedure was done via right Detailed_description femoral Detailed_description artery Detailed_description approach Detailed_description , and severe Severity left Biological_structure SCA Biological_structure stenosis Sign_symptom was confirmed (Fig.2A) (Supplementary Video 1, only online).
Direct Detailed_description stenting Therapeutic_procedure in the left Biological_structure SCA Biological_structure was carried out with a balloon Detailed_description - expansible Detailed_description Express Detailed_description LD Detailed_description 10×25 Detailed_description mm Detailed_description stent Detailed_description ( Boston Detailed_description Scientific Detailed_description Corporation, Detailed_description Natick, Detailed_description MA, Detailed_description USA Detailed_description ) (Fig.2B) up to 8 Lab_value atmospheres Lab_value for Lab_value 13 Lab_value seconds Lab_value .
However, severe Severity shortness Sign_symptom of Sign_symptom breath Sign_symptom and hypotension Sign_symptom developed after stenting Coreference .
The blood Diagnostic_procedure pressure Diagnostic_procedure was down to 88/56 Lab_value , and the heart Diagnostic_procedure rate Diagnostic_procedure was up to 90 Lab_value .
The oxygen Diagnostic_procedure saturation Diagnostic_procedure was down to 74% Lab_value .
Emergent Detailed_description intubation Therapeutic_procedure , fluid Therapeutic_procedure infusion Therapeutic_procedure , inotropic Medication agent Medication with norepinephrine Medication were given.
The immediate Detailed_description angiography Diagnostic_procedure showed vascular Sign_symptom perforation Sign_symptom in the stented Biological_structure segment Biological_structure of Biological_structure left Biological_structure SCA Biological_structure (Fig.2C) (Supplementary Video 2, only online).
Emergency balloon Therapeutic_procedure inflation Therapeutic_procedure within Biological_structure the Biological_structure stent Biological_structure was done with an 8×40 Detailed_description mm Detailed_description balloon Detailed_description .
The cardiovascular Nonbiological_location surgeon Nonbiological_location was also consulted Clinical_event .
However, due to the high surgical risk of bypass, endovascular Therapeutic_procedure treatment Therapeutic_procedure was suggested.
We decided to do a retrograde Therapeutic_procedure approach Therapeutic_procedure through the left Biological_structure brachial Biological_structure artery Biological_structure by Detailed_description surgical Detailed_description cut Detailed_description - down Detailed_description .
Since there was no suitable graft stent in our cath lab, we modified Detailed_description and Detailed_description cut Detailed_description the Detailed_description iliac Detailed_description extension Detailed_description of self Detailed_description - expanding Detailed_description Endurant Detailed_description II Detailed_description graft Detailed_description stent Detailed_description 10×82 Area mm Area ( Medtronic, Detailed_description Inc., Detailed_description Minneapolis, Detailed_description MN, Detailed_description USA Detailed_description ), which was originally designed to treat abdominal aortic aneurysms (AAA), to a suitable length ( around Detailed_description 30 Detailed_description mm Detailed_description ) (Fig.3).
After retrograde wiring, an operator-modified Endurant II graft Therapeutic_procedure stent Therapeutic_procedure was deployed in the stent segment (Fig.2D) and the perforation Therapeutic_procedure was Therapeutic_procedure sealed Therapeutic_procedure successfully.
After stenting of the graft stent, however, slow Lab_value flow Diagnostic_procedure of left Biological_structure common Biological_structure carotid Biological_structure artery Biological_structure ( LCCA Biological_structure ) was noted, and angiography Diagnostic_procedure confirmed the near Severity total Severity occlusion Sign_symptom of the LCCA Biological_structure , occluded Detailed_description by Detailed_description the Detailed_description SCA Detailed_description graft Detailed_description stent Detailed_description (Fig.2E) (Supplementary Video 3, only online).
A firm Therapeutic_procedure wire Therapeutic_procedure (Conquest pro, Asahi Inc, Seto, Japan) was successfully advanced Detailed_description outside Biological_structure the Biological_structure graft Biological_structure stent Biological_structure and into the LCCA Biological_structure .
Despite sequent balloon Therapeutic_procedure dilations Therapeutic_procedure at the bifurcation Biological_structure site Biological_structure , the flow Diagnostic_procedure to the LCCA Biological_structure was still poor Lab_value .
Intravascular Detailed_description ultrasound Diagnostic_procedure also confirmed the severe Severity compromise Sign_symptom of the LCCA Biological_structure ostium Biological_structure which was caused Detailed_description by Detailed_description the Detailed_description graft Detailed_description stent Detailed_description (Fig.2F).
Therefore, we put a balloon Detailed_description - expansible Detailed_description carotid Therapeutic_procedure stent Therapeutic_procedure , Express Detailed_description 7×37 Detailed_description mm Detailed_description ( Boston Detailed_description Scientific Detailed_description Corporation Detailed_description ), from Biological_structure the Biological_structure LCCA Biological_structure to the left Biological_structure brachiocephalic Biological_structure artery Biological_structure (Fig.4A).
TIMI Diagnostic_procedure III Diagnostic_procedure flow Diagnostic_procedure of the LCCA Biological_structure was restored Lab_value after stenting (Fig.4B-E) (Supplementary Video 4, only online).
Intravascular Detailed_description ultrasound Diagnostic_procedure also confirmed proper Lab_value expansion Sign_symptom of the LCCA Biological_structure stent Biological_structure (Fig.4F).
The follow Clinical_event - up Clinical_event chest Biological_structure radiography Diagnostic_procedure revealed left Detailed_description - side Detailed_description hemothorax Sign_symptom .
After thoracocentesis Therapeutic_procedure with drainage Detailed_description and proper Therapeutic_procedure care Therapeutic_procedure , the patient was discharged Clinical_event .
Till now, the patient has been free from symptoms Sign_symptom for six Duration months Duration .