em2177
Expert
Need assistance in coding this report. 93458,26/92980,RC/33210? Is this correct?
REASON FOR EVALUATION: Unstable angina.
HISTORY OF THE PRESENT ILLNESS: This patient is well-known to me for a recent
diagnosis of unstable angina and abnormal nuclear scan. The patient went on to
have an angiogram with a total occlusion of a very heavily calcified RCA. We
were able to traverse such and open up with balloon angiopiasty. At that time
we felt it was more prudent, now that we reestablished TIMI-3 flow, to prepare
for Rotablator and stenting. The patient has been explained the complete
risks, benefits, and alternatives of Rotablator of the RCA, need for a
temporary pacemaker, angiopiasty and stenting, and the patient is eager to
proceed. Chemistry panel has been quite stable. The patient has been on
Plavix therapy.
PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Lidocaine was placed to the left
common femoral area, and then a 6-French sheath was placed to the left common
femoral vein. A 7-French sheath was placed to the left common femoral artery.
Angiography of the arterial site was performed. Next, under fluoroscopic
guidance, a temporary pacemaker was placed into the RV with good capture and
was set at 3 ma and backup heart rate of 40. Next heparin was given per
weight-based protocol, and a 7-French JR4 with side holes was placed to the
ostium of the RCA. A Luge wire was placed in the distal posterolateral branch,
and a 1.5 balloon was placed distally. The Luge wire was removed, and the
stiff RotaWire was placed through the balloon and balloon was removed.
At this time a 1.25 bur Rotablator was prepped in a standard fashion and was
placed to the proximal RCA. Rotablator of the proximal segment was performed
in serial staging, and a polishing run was performed with this 1.25 bur. Then
the Rotablator bur was placed into the mid-to-distal segment in multiple runs.
This area was performed with a 1.25 bur. DynaGlide was used to remove the 1.25
bur. Then 100 meg of nitroglycerin was given. Angiography was performed.
At this point a 1.5 bur was placed to the proximal RCA, and multiple runs,
again with a polishing run of the proximal segment, were performed. Next the
1.5 bur was placed in the mid-to-distal segment, again with multiple runs and a
polishing run to complete. It was removed via DynaGlide. Rotablator was
removed. Angiography was performed. There was significant improvement in
flow. There was a question of a small dissection. Thus, no further Rotablator
was performed.
At this point a 3.0 x 15 Apex balloon was placed into the distal RCA. The
RotaWire was removed and the Luge wire was placed in the posterolateral branch.
The balloon was brought back to the mid-to-distal segment, and serial
dilatation all the way up to the proximal segment was performed to 16
atmospheres. Balloon was brought back. Then 200 meg of nitroglycerin was
given. Repeat angiography was performed.
Next a 3.5 x 20 Integrity non-drug-eluting stent was placed into the
mid-to-distal segment, where we had rotablated and ballooned. We chose a
non-drug-eluting stent, as the patient needs multiple orthopedic operations for
severe pain in the very near future, and this is now a large vessel. This was
inflated to 16 atmospheres. SDS system was brought back. Nitroglycerin was
given. Angiography was performed.
Next a 4.0 x 30 was placed in overlapping fashion, extending from the mid
vessel all the way to the proximal, just after the ostial segment of the RCA,
covering the entire lesion. Angiography was performed, and then this was
inflated to 16 atmospheres. SDS system was removed.
At this point a 4.0 post dilatation balloon was able to be placed into the
distal stented segment using a buddy wire. Buddy wire was removed, and serial
dilatation over the extended length of the stented segment, including the
overlapping segment, was performed to 14-16 atmospheres.
The balloon was removed. Then 1000 meg of nitroglycerin was given. Repeat
angiography was performed. Wire was removed, and multiple-view angiography
again was performed. The catheter was removed and Angio-Seal was placed to the
left common femoral artery. Manual pressure was also held to artery and vein.
There was small oozing around the sheaths throughout the procedure. Thus, it
was felt prudent to also use a FemoStop. There was good groin hemostasis. The
patient remained hemodynamically stable and was asymptomatic.
IMPRESSION:
1. Pre procedure the RCA was a very heavily calcified lesion, extending from
the proximal segment through the mid segment into the mid-to-distal area,
just past an RV branch. Status post Rotablator and stenting from distally
to proximally with a 3.5 x 20 and a 4.0 x 30 in overlapping segments with
Integrity non-drug-eluting stent with 4.0 post dilatation reveals 0%
residual stenosis, TIMI-3 flow of the entire segment. It appears to have
good wall apposition.
2. Temporary pacing was not required, and temporary pacemaker was removed.
REASON FOR EVALUATION: Unstable angina.
HISTORY OF THE PRESENT ILLNESS: This patient is well-known to me for a recent
diagnosis of unstable angina and abnormal nuclear scan. The patient went on to
have an angiogram with a total occlusion of a very heavily calcified RCA. We
were able to traverse such and open up with balloon angiopiasty. At that time
we felt it was more prudent, now that we reestablished TIMI-3 flow, to prepare
for Rotablator and stenting. The patient has been explained the complete
risks, benefits, and alternatives of Rotablator of the RCA, need for a
temporary pacemaker, angiopiasty and stenting, and the patient is eager to
proceed. Chemistry panel has been quite stable. The patient has been on
Plavix therapy.
PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Lidocaine was placed to the left
common femoral area, and then a 6-French sheath was placed to the left common
femoral vein. A 7-French sheath was placed to the left common femoral artery.
Angiography of the arterial site was performed. Next, under fluoroscopic
guidance, a temporary pacemaker was placed into the RV with good capture and
was set at 3 ma and backup heart rate of 40. Next heparin was given per
weight-based protocol, and a 7-French JR4 with side holes was placed to the
ostium of the RCA. A Luge wire was placed in the distal posterolateral branch,
and a 1.5 balloon was placed distally. The Luge wire was removed, and the
stiff RotaWire was placed through the balloon and balloon was removed.
At this time a 1.25 bur Rotablator was prepped in a standard fashion and was
placed to the proximal RCA. Rotablator of the proximal segment was performed
in serial staging, and a polishing run was performed with this 1.25 bur. Then
the Rotablator bur was placed into the mid-to-distal segment in multiple runs.
This area was performed with a 1.25 bur. DynaGlide was used to remove the 1.25
bur. Then 100 meg of nitroglycerin was given. Angiography was performed.
At this point a 1.5 bur was placed to the proximal RCA, and multiple runs,
again with a polishing run of the proximal segment, were performed. Next the
1.5 bur was placed in the mid-to-distal segment, again with multiple runs and a
polishing run to complete. It was removed via DynaGlide. Rotablator was
removed. Angiography was performed. There was significant improvement in
flow. There was a question of a small dissection. Thus, no further Rotablator
was performed.
At this point a 3.0 x 15 Apex balloon was placed into the distal RCA. The
RotaWire was removed and the Luge wire was placed in the posterolateral branch.
The balloon was brought back to the mid-to-distal segment, and serial
dilatation all the way up to the proximal segment was performed to 16
atmospheres. Balloon was brought back. Then 200 meg of nitroglycerin was
given. Repeat angiography was performed.
Next a 3.5 x 20 Integrity non-drug-eluting stent was placed into the
mid-to-distal segment, where we had rotablated and ballooned. We chose a
non-drug-eluting stent, as the patient needs multiple orthopedic operations for
severe pain in the very near future, and this is now a large vessel. This was
inflated to 16 atmospheres. SDS system was brought back. Nitroglycerin was
given. Angiography was performed.
Next a 4.0 x 30 was placed in overlapping fashion, extending from the mid
vessel all the way to the proximal, just after the ostial segment of the RCA,
covering the entire lesion. Angiography was performed, and then this was
inflated to 16 atmospheres. SDS system was removed.
At this point a 4.0 post dilatation balloon was able to be placed into the
distal stented segment using a buddy wire. Buddy wire was removed, and serial
dilatation over the extended length of the stented segment, including the
overlapping segment, was performed to 14-16 atmospheres.
The balloon was removed. Then 1000 meg of nitroglycerin was given. Repeat
angiography was performed. Wire was removed, and multiple-view angiography
again was performed. The catheter was removed and Angio-Seal was placed to the
left common femoral artery. Manual pressure was also held to artery and vein.
There was small oozing around the sheaths throughout the procedure. Thus, it
was felt prudent to also use a FemoStop. There was good groin hemostasis. The
patient remained hemodynamically stable and was asymptomatic.
IMPRESSION:
1. Pre procedure the RCA was a very heavily calcified lesion, extending from
the proximal segment through the mid segment into the mid-to-distal area,
just past an RV branch. Status post Rotablator and stenting from distally
to proximally with a 3.5 x 20 and a 4.0 x 30 in overlapping segments with
Integrity non-drug-eluting stent with 4.0 post dilatation reveals 0%
residual stenosis, TIMI-3 flow of the entire segment. It appears to have
good wall apposition.
2. Temporary pacing was not required, and temporary pacemaker was removed.