Pigtail catheter was passed via inferior venacava to right atrium to right ventricle to main pulmonary artery. Injection was taken.

Image

Video

tetralogy of fallot angiogram 1

This shows adequately sized main, right and left pulmonary arteries. In levophase, left sided chambers can be seen filling.

Pigtail catheter was passed through femoral artery to aortic root to left ventricle and injection was made.

Image

Video

This left ventriculogram in LAO view shows aortic override and a large subaortic VSD. Dye can be seen entering the right ventricle.The override is about 50%.

He gave history of exertional dyspnoea class II of 3 months duration. ECG showed LBBB. Echo showed mild concentric LVH, no RWMA and good LV function.

His coronary angiogram is shown below.

The first film is an RAO caudal view showing tight ostial stenosis of dominant LCx. The second film is an LAO cranial view showing 50% proximal LAD stenosis.

His stress myocardial perfusion image is shown below.

This shows mild reversible perfusion defect in the septum. This may be due to coronary disease or it may be an LBBB artifact.

The dilemma in this case is-

ESRD patient needs renal transplant. Has tight ostial stenosis of dominant LCx. No angina. SPECT inconclusive. What to do?

• Renal transplant directly
• CABG followed by renal tranplant
• PCI followed by renal tranplant

Let us examine the ACC AHA criteria for coronary revasularization-

Revascularization is not indicated (class III) in the following situations-

• 1. Use of PCI or CABG for patients with one- or two vessel CAD without significant proximal LAD CAD, who have mild symptoms that are unlikely due to myocardial ischemia, or who have not received an adequate trial of medical therapy and
  
  • a. have only a small area of viable myocardium or
  • b. have no demonstrable ischemia on noninvasive testing. (Level of Evidence: C)
• 2. Use of PCI or CABG for patients with borderline coronary stenoses (50% to 60% diameter in locations other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing. (Level of Evidence: C)
• 3. Use of PCI or CABG for patients with insignificant coronary stenosis (less than 50% diameter). (Level of Evidence: C)
• 4. Use of PCI in patients with significant left main coronary artery disease who are candidates for CABG. (Level of Evidence: B)

The parts in the class III recommendation that are relevant in the present situation are underlined.

Thus in this patient with single vessel disease that does not involve significant proximal LAD disease with mild dyspnoea which is most likely a part of the fluid overload state of ESRD than due to coronary ischemia and with only a small area of involved myocardium, revascularization is not indicated.

Named after the ophthalmologist, Takayasu.

Begins in the second decade.

Delay from onset to diagnosis is 15 months.

Aetiopathogenesis

The hypothesized mechanisms are TB, viral infections, autoimmunity and genetic factors.

Histology

Panarteritis in acute phase.

Fibrosis of all layers in chronic phase leads to stenosis. Lack of fibrosis leads to aneurysms.

Patchy affection with skipped areas.

Clinical phases

Early phase- inflammation

Vascular phase- stenosis (93%) or aneurysm (7%)

Burnt out phase- remission

Classification

Ishikawa classification- into groups. I – uncomplicated. II- single complication (A- mild/moderate, B- severe). III- two or more complications. Complications included are AR, aneurysm, retinopathy and hypertension.

American College of Rheumatology criteria- 3 out of 6 of the following needed to diagnose TA. Age < 40 yrs, claudication, decreased brachial pulse, arm BP difference > 10 mmHg, aortic or subclavian bruit and arteriogram showing aortic or branch stenosis not typical for atherosclerosis or fibromuscular dysplasia.

Sharma modified criteria for diagnosis of TA- two major, one major and two minor or four minor needed. Major criteria are left mid subclavian A lesion, right midsubclavian A lesion and characteristic signs and symptoms of > 1 months duration. Minor criteria are carotodynia, hypertension, AR, ESR > 20, pulmonary A lesion, coronary A lesion, distal innominate A lesion, left middle common carotid A lesion, descending thoracic aorta lesion and abdominal aortic lesion.

Serological markers

ESR has low sensitivity and specificity as a marker of disease severity. IL-6, RANTES, MMP-3 and MMP-6 may be useful.

Radiologic findings

ACR classification is as in the figure below. Add C+ or P+ for coronary or pulmonary artery involvement respectively.

PET and Doppler are useful for follow-up. Chest X-ray may show linear calcification of aortic arch and descending thoracic aorta.

Treatment

Medical management is with corticosteroids first followed by other immunosuppressive drugs if there is no response [prednisone at 0.7-1 mg/kg/day for 1-3 months, cyclophosphamide (1-2 mg/kg/day), azathioprine (1-2mg/kg/day), or methotrexate (0.3 mg/kg/week)].

Surgical or endovascular treatment for vascular complications.

Follow-up

Active disease is present if at least two of the following four criteria are present (Sabbadini et al, 2001)- systemic features, elevated ESR, signs and symptoms of vascular ischaemia or inflammation and typical angiographic features.

TTE PLAX view of a patient with mitral stenosis is shown (diastolic frame). Red marker points to aorta, blue marker points to left ventricle and yellow marker points to left atrium. The left atrium is dilated. There are two clots in the left atrium (white markers). Spontaneous echo contrast can be seen in the left atrium. The mitral valve opens poorly suggestive of mitral stenosis.

Diagnosis- Severe mitral stenosis with left atrial clots.

MI patient presents to a hospital with ability to do PCI within 90 minutes of admission and within 60 minutes of time in which fibrinolysis can be given. The patient has good vascular access for PCI. Ask these questions.

1. Doubt whether MI or not?
   1. Yes- PCI
   2. No- go to next question.
2. Time of onset –
   1. More than 3 hours- PCI.
   2. Less than 3 hours- go to next question.
3. Killip class-
   1. II or more- PCI
   2. I- go to next question.
4. Bleeding risk? (age 65, low body weight, high BP)
   1. Present- PCI
   2. Absent- tPA or PCI.