CaseStudy

58 years male was admitted for PTCA with a highly calcified LAD artery showing 90% blockage and another 90% blockage in its side branch.

Highly calcified artery makes angioplasty very challenging as calcium present in the arteries doesn’t allow the stent to expand. The patient underwent Rota Ablation with a OCT Guided PTCA by Dr Ankur Phatarpekar.

Rota Ablation is a technique in which a burr rotating at very high speed drill is used to pulverise calcium unblocking the artery.

To know the right position of the stent we use a technique called OCT (Optical Coherence Tomography) which helps us to decide the exact placement, sizing and apposition to ensure proper expansion of stent providing long term result.

With the availability of both the technologies & experienced doctors we could achieve a very challenging Angioplasty at our Hospital.

A 67-year-old male patient with a history of dyspnoea of exertion since 1 month which worsened since 15 days. He was diagnosed with severe Aortic Valve Stenosis.

On Examination

Vitals Stable

CVS – EFM Systolic Murmur

Management/ Progress in Hospital

He underwent TAVI (Trancatheter Aortic Valve Implantation) under local Anaesthisia + Sedation by Dr. Ankur Phatarpekar and his team through right femorial artery.

Post procedure was shifted to ICU with stable Haemodynamic for observation.

Post procedure ECG sinus rhythm no ST-T changes.

After 24hrs left femorial sheaths were removed.

He was mobilised out of the bed.

Beta Blockers with held in view of Borderline Bradycardia.

Post Procedure Echo Screening.

Investigation

Pre-Operative

2D-Echo – Gross Concentric LVH. All chambers normal size. Mild and distal septum mildly hypokinetic. Heavily calcified Aortic valve with reduced opening with peak by mean gradient of 86/53 mm of Hg suggestive of Severe AS with Grade ¼ AR. Grade ¼ MR, Grade ¼ AR. No evidence of PR/TR. No significant gradient across LVOT/RVOT. Normal LVEF – 61%

Post- Operative

2D-ECHO- Normal LV systolic function. k/c/o degenerative Severe AS , s/p TAVI with normally functioning of Aortic valve. Mild Concentric LVH. All chambers normal size.

Bioprosthetic Aortic valve in situ, opening well. No e/o paravalvular leak.

Grade I MR. No evidence of AR/PR/TR. Peak by mean gradient across Aortic valve is 28/16 mm of Hg. AVA by continuity is 1.43 sq.cm.

LVEF 65%.

Operative Notes

Right femorial and left femorial artery venous punctured.

Left femorial side 6-F sheath introduced in both venous and artery.

Right common femorial artery 10-F sheath introduced.

23 size balloon used for commissurotomy and inflated for 3 seconds.

Ventricle with pacing at 180 beats/min gradiant aortic valve – nil.

Following commissurotomy 23 size MyVal pericardial, bioprothes crimpel introduced and implanted across aortic valve with ventricular pacing of 180 beats/min.

Result – Valve position intra-annular

No para valvular leak.

Good result.

Right femorial cannulation closed with proglide.

2 proglide used.

Good haemostasis.

Patient tolerated procedure well.

A 70 years male was admitted and diagnosed with abdominal aorta aneurysm for planned abdominal aortic aneurysm stenting. He had history of low back pain for 2 years. His Follow up scan showed increase in size of Aortic Aneurysm with rapid progression of disease in Right Iliac artery. Considering his advanced age and co morbidities, patient was not willing for surgery and opted for minimal intervention.

After detailed evaluation patient underwent Abdominal Aortic stent grafting under general anaesthesia. Patient tolerated the procedure well and shifted to the ICU. All invasive lines removed gradually. He was treated with IV Antibiotics, LMWH, DAPT, Statin, Beta blocker and other supportive measures. The patient's postoperative course was uneventful and he was discharged on postoperative Day 4 with no renal impairment.

Procedure/Surgery Name: Geniculate Artery embolization for Recurrent Hemarthrosis

Doctors: Dr Bhavesh Arun Popat, Dr Karan M Anandpara

Pre-Op Details & Diagnosis

A 72 years old male

Comorbidities: Morbidly obese, poorly controlled diabetes, hypertensive, previous H/O CABG.

Complaints: Bilateral knee pain, joint aches and soreness (left>right knee).

Pain after joint overuse.

Reduced physical activity and quality of life.

Local knee tenderness +.

X ray bilateral knee s/o bilateral osteoarthritic changes (left more than right).

H/O left sided recurrent hemarthrosis for which percutaneous USG guided aspiration of fluid done outside.

USG local part suggestive of left sided hemarthrosis – hyperechoeic fluid with septations in the left knee joint cavity.

MRI done s/o changes of severe osteoarthritis with left sided hemarthrosis

Pain not relieved by conservative medical management i.e. by anti-inflammatory drugs or corticosteroids.

Not relieved by intra-articular steroid injection.

Not a candidate for joint replacement/arthroplasty in view of significant medical comorbidities, contraindications for general anaesthesia and patient’s refusal for knee arthroplasty.

Treatment Plan

Planned for Left sided Geniculate Artery Embolization in view of recurrent hemarthrosis and left joint pain.

Details about the Procedure/Surgery:

Procedure under local anesthesia. Groin prepared.

Left Common Femoral Artery antegrade access.

DSA Angiogram done which showed hypertrophied superior and inferior medial geniculate arteries.

Synovial vascular blush noted.

Super selective cannulation of the superior and inferior geniculate arteries done using Progreat microcatheter.

Embolization done with PVA particles.

Post Procedure Details:

Post procedure DSA showed reduction in the synovial vascularity. Reduced arterial blush noted.

Sheath removed by manual compression.

Patient discharged on same day.

Significant reduction of pain on 1 and 3 month follow up.

Conclusion

Geniculate artery embolization (GAE) reduces pain of osteoarthritis by decreasing the vascular supply to the hypertrophied and inflamed synovium and has a role in cases of recurrent hemarthrosis.

It is safe, effective and minimally invasive.

No cuts, no stitches are required.

It can be Performed under local anesthesia.

No general anaesthesia needed.

It is a day care procedure with a same day discharge.