Transcription
Good morning, everybody. Let me first thank the organizing committee for the nice invitation for this, for this complications session. My case is about a 64-year-old lady with a history of breast cancer that was treated with surgery, radiation, and chemotherapy, and she's still on tamoxifen for long-term therapy. She presented with intestinal obstruction, and the workup showed a colonic mass, and resection biopsy was recommended.
She had pre-op evaluation done as an outpatient that included ECG and pre-op lab, and according to the, uh, cardiologist who saw her, that she was, she's fit for surgery. She was admitted to the hospital three days before surgery. Colonoscopy was done, and abdominal surgery was done the day after colonoscopy. According to the surgeon, he found a mass and he decided just to do a colostomy just to relieve the obstruction. She did not receive any anticoagulation or DVT prevention except for pneumatic compression post-op.
On the first post-op update in the morning, she developed chest pain, and at that time, the cardiology consult was requested, and the cardiac markers were elevated. Troponin was more than a thousand. ECG was done, and she was started—she was not started on any anticoagulation because, you know, the surgeon is always afraid to start any patient post-op on any anticoagulation or anti-platelet, and no workup was done for her hypercoagulability at that time. And she was—everybody recommended just call the cardiologist and let her—let's take her to the cath lab. At that time, I asked to be loaded for—with aspirin, anti-coagulation—this is her ECG, and you see that there is this T-wave changes in the anterior leads. So this is the angiogram, and there were no—nothing in the LAD that we were expecting to see, and there is some a minor lesion in the proximal circumflex. And again, this is a borderline lesion in the proximal circumflex, and another view for the LAD showing no—no obvious lesion. Anyways, I decided to do, uh, FFR for that lesion in order to see what, uh, the plan—and anyway, the FFR was, uh, negative. IFR was 94, and the, uh, after doing adenosine infusion, the FFR was around 87. This is her right coronary artery; also, there is no obvious lesion. So I just recommended putting her on DAPT. This is an NSTE-MI with no significant obstruction. I decided not to do any stenting. Recommended DAPT and no low molecular weight heparin, but the surgeon refused to—to—to give her those medications.
On the second morning post-cath, she developed right-sided weakness, and the head CT showed cerebral infarct in the left middle cerebral artery. A neurology consult was requested, and the neurologist discussed the option—just you gave her this stroke, this, and you have to intervene for—for that. I said this is the lesion on the, uh, left middle cerebral artery, and I went from the right radial. It's very, uh, unlikely, but—and since this happened later, not during the procedure, but, uh, anyway, the, uh, he did not recommend any anticoagulation, and no further neuroimaging was done, and no workup for hypercoagulability was done at that time.
Later in the same day, she was noted to have a cold right hand, and now everybody came—you gave her this complication, this is from your radial axis. So paleness of the fingers and the right hand—of the right hand was noted. Ultrasound test report confirmed that there is total occlusion in the right subclavian artery, and no evaluation was done by the vascular surgery. Again, called the cardiologist—he's responsible for that—and no therapy with anticoagulation was started because the surgeon said she's post-op and she is at high risk for bleeding. So I was called for a bailout for the procedure. I arrived in the evening and examined the patient, reviewed the chart—of importance of that—again, no workup for hypercoagulability in this high-risk patient. She has cancer of the breast and now suspecting cancer of the colon, and her COVID-19 status was unclear and undocumented in the chart. So I asked for a PCR sample for COVID-19 and sent blood for the D-dimer, coagulation profile, and hypercoagulability workup, and I took her for emergency procedure for this right subclavian after obtaining a consent. And we entered the cath lab around 9 PM. So this is the angiogram, and you see that she has obstruction of the—sorry, let's go back. Okay, okay. The obstruction of the proximal right subclavian and this area of long total occlusion. It's both—I have fixed picture and filmed. So with that, I'm a cardiologist, so I do peripheral things with my cardiology equipment. So you see I got a coronary wire and looped it. You see the looped wire, and just with the loop I was able to cross this area of total occlusion and tried dilating that with the four-millimeter balloon, and you see with that there is no, uh, dissection, but there is a big thrombus burden. You see this white area on this, uh, DSA. So, uh, now we opened the R3, but there is a big thrombus burden. Look at that—just by injection—and you see now the clot is moving and embolizing distally after I did this, uh, pre-dilation. And this is the angiogram after this pre-dilation with the balloon, and you see the clot is moving and embolizing distally. And now blocked moved from the subclavian to the brachial artery. So with this, uh, uh, over-the-wire balloon, I, uh, went with the over-the-wire balloon distally beyond the brachial artery and did angiogram by the tip of the, uh, from the tip of this balloon, and you see this study—there is good flow to both radial and the R3. So it is not a complication of a radial axis, at—at least, but, uh, anyway. So I had to continue still this big thrombus burden, and you see now the clot continues to move and move distally, although I was doing aspiration both with export catheter and with the manual aspiration. I have six Frenchies—this is six Frenchies—and I went the sheath and did my manual aspiration many times in order to aspirate the clot. I did get some clot out, but still this is a big clot burden, and the clot kept moving distally. One minute for you, yeah. Okay. So, uh, this is—so I—I went with a dilation distally—this is at the, uh, radial artery—and we got the radial artery open, and look at this angiogram—now the radial is open, but the ulnar R3 is not open. So I switched the wire to the ulnar R3, and now the ulnar R3 is open, but we got back—close the radial artery. So I had to do kissing distally, and by kissing that we got the good angiogram. There is some residual clot, but this is the angiogram now—the bifurcation to ulnar radial are patent, and this is the angiogram showing good flow all the way down to the hand with filling both the ulnar and the radial. And this is the—the final, uh, angiogram at the proximal subclavian. No—no—where else can I have just the last part—the final slide—the final result—the final slide shows us the final result. So, uh, since you know she had some, uh, TIA or so, I had to check the brain before leaving the cath lab, and there is no clot in the middle, uh, left middle cerebral artery on both an, uh, anterior—anterior and lateral, and I have to check the carotid, and also the carotid is fine. So after the intervention, I started her on a P2Y12 inhibitor. She continued to have a radial pulse, transferred to the RCU, and started her on low molecular weight heparin with a therapeutic dose. So now, if that a complication of my intervention, or—just let me tell you that we got the result of PCR was positive, and we got the D-dimer sky high, we got the anti-phospholipid high—that's for the COVID in an acute case. So what's that—is that due to COVID, and that gives her her thrombosis in the subclavian and thrombosis in the cerebral artery, or what—what that—please. I'm waiting for your comments. Thank you very much. Thank you. Thank you very much, you.