bhargavi
Guru
Reason for angiogram: Acute stroke with middle cerebral artery M1 occlusion Brief history: Patient with major comorbidities and complications that includes uncontrolled hypertension, noncompliant , prior history of right internal carotid artery CEA , acute CHF hyperlipidemia, acute respiratory failure requiring intubation presented to the ED with the vision loss and also during initial evaluation started having weakness of his left side .patient was intubated in the emergency room and was given IV TPA and subsequently was taken to Cath Lab for thrombectomy . Informed consent: Consent was taken from patient's wife over the phone. procedure was explained to the patient in layman terms. The risk of the procedure which includes but not limited to groin hematoma, retroperitoneal hematoma, procedure failure, contrast neohropathy, Major and minor stroke, vascular dissection and death was explained to the patients in layman terms. All questions were appropriately answered, patient and patient family elected to have the above procedure performed. Anesthesia: General anesthesia. Patient was intubated and managed by me with Cath Lab nurse face-to-face. Procedures performed:
Description of procedure: patient was brought to angio suite and identified using multiple patient identifiers. Time out was performed by entire team. Patient was placed in supine position on angiography table and bilateral ground and right wrist was cleaned using beta fine solution. Sterile drape was applied. Right femoral artery was palpated and under ultrasound 8 French sheath was placed using micro puncture kit and modified Seldinger technique. This was sutured and continuously flushed with pressurized heroism saline. 8 French balloon guide catheter was navigated over penumbra select 5 French catheter and exchange length 0.035 mm guidewire. Under fluoroscopy and roadmapping technique the balloon guide catheter was taken into internal carotid artery on the left and was deployed at right common carotid artery Once the guide catheter was deployed angiogram was done which confirmed the occlusion 100% of the right internal carotid artery just distal to the origin with no flow beyond the origin of the internal carotid artery. At that time microcatheter using Synchro standard wire was used and microcatheter was navigated under fluoroscopy and roadmapping taking distally into distal internal carotid arteries ophthalmic segment. At that time stent retriever solitaire 6 x 40 mm was deployed for 3 minutes and subsequently withdrawn under constant aspiration using aspiration pump. At this point CAT 7 aspiration catheter was taken over velocity microcatheter and Synchro standard wire under fluoroscopy and roadmapping technique CAT 7 was deployed at distal cervical segment of the carotid artery and aspiration was attempted using aspiration pump Subsequently after deploying stent retriever and cath 7 with unsuccessful revascularization of the carotid artery, aviator balloon 4 x 30 was navigated to the carotid artery and angioplasty was done 3 types. That resulted in proximal internal carotid artery vascularization but again distal carotid artery showed no flow. Once again at that time stent retriever 6 x 40 was deployed and under aspiration it was retrieved. There was no flow of the carotid artery After attempting over 90 minutes it was decided then to abort the procedure as there was no flow and all devices were deployed multiple times with no success This point patient was examined and all the catheter was taken out and his groin was sealed with Angio-Seal 8 French. Complications - None Interpretation : Right internal carotid artery angiogram, neck and head -right carotid artery angiogram demonstrated complete 100% occlusion just distal to the origin of the right internal carotid artery with no flow distal to the. The right external carotid artery appears normal with normal-appearing branching. There were no collaterals seen from the external carotid artery to the intracranial carotid artery. Right internal carotid artery angiogram head and neck post thrombectomy: Angiogram of the right carotid artery post multiple attempts of angioplasty, aspiration using aspiration catheter, declined multiple times stent retriever there was no flow in the right internal carotid artery. Left internal carotid artery angiogram, head and neck: Angiogram of the left common carotid artery demonstrate normal appearing common carotid artery which bifurcates into left internal carotid artery and left external carotid artery. The left internal carotid artery at the origin demonstrate mild atherosclerotic disease. Left internal carotid artery petrous cavernous segment demonstrate normal appearing petrous cavernous segment. The left internal carotid artery intracranially divides into left middle cerebral artery left anterior cerebral artery. The left middle cerebral artery appears normal with normal-appearing superior inferior segment and distal branches. The left anterior cerebral artery appears normal. There is no flow to the contralateral right hemisphere from the left internal carotid artery. Right common femoral artery angiogram- Right CFA angiogram demonstrate normal appearing right CFA proximally with normal bifurcation. The site of arteriotomy appears well above bifurcation of CFA. Impression: 1. Unsuccessful revascularization of the right internal carotid artery complete occlusion with no flow in the right internal carotid artery and also no flow seen in the right middle cerebral artery. 2. Angiogram of the left internal carotid artery demonstrated normal appearing left internal carotid artery with normal-appearing left middle cerebral artery and left anterior cerebral artery with no flow to the contralateral side. |
thanks in advance
should I do 61645?
physician billed 36224, 36228, 61650, 61651, 61645, 61630