PROCEDURE PERFORMED:
1. Left heart catheterization with selective right and left coronary angiography via left common femoral approach.
2. Selective left internal mammary angiography to the LAD via left radial approach.
INDICATIONS FOR PROCEDURE: This patient is presenting with increasing anginal symptoms despite medical therapy and an abnormal Cardiolite stress test.
COMPLICATIONS: None.
TOTAL CONTRAST: 80 mL.
DESCRIPTION OF PROCEDURE: The patient was brought to the cath lab after informed and signed consent was obtained. The left radial area was draped and prepped in a sterile surgical fashion. The right inguinal area was draped and prepped in a sterile surgical fashion. Vascular access was obtained in the left radial artery with a long 6-French hydrophilic sheath.
Using 5-French diagnostic TIG catheter, I attempted tried to cannulate the left main but was unsuccessful due to the tortuosity. I also was not able to cannulate the right coronary artery. I was able to cannulate the vein graft to the circumflex vessel. This catheter has been repositioned in the subclavian artery and selective left internal mammary artery angiography to the LAD was performed. This catheter was then removed.
Vascular access was then obtained through the left common femoral artery with a 6-French introducer sheath. Using a 5-French 3.5 JL4 diagnostic catheter, the left main was cannulated and left coronary angiography were then performed in orthogonal views. This catheter was removed and exchanged for a 5-French JR4 diagnostic catheter. It was placed in the right
coronary ostium and right coronary angiography was then performed. This catheter was then repositioned into the vein graft to the right coronary artery and again vein graft angiography to the right coronary artery was also performed. Note that while the TIG catheter was in place, it was placed across the aortic valve. Hemodynamics were obtained including pullback
pressures.
FINDINGS:
1. The left main is a relatively large vessel that does have superficial calcification. It gives rise to a left anterior descending and left circumflex system and is free of significant stenosis.
2. The left circumflex vessel has a very high obtuse marginal vessel that is a 1.5+ mm vessel and has mild luminal irregularities. It course out toward the lateral apical segment. The circumflex artery itself terminates, is occluded in its proximal segment.
3. The left anterior descending artery has diffuse calcification present throughout its proximal segment. It gives rise to a very large diagonal vessel that has a diffuse 55% stenosis. The LAD itself in the mid segment has a subtotal stenosis. There is competitive flow visualized from the LIMA graft.
4. The right coronary artery is occluded in its proximal segment.
5. Vein graft to the right coronary artery is patent. It inserts on the distal RCA. The PDA is a relatively small vessel with diffuse atherosclerotic disease.
6. The vein graft to the circumflex is occluded in its proximal segment.
7. The LIMA to the LAD is widely patent. It inserts on the mid LAD. The mid and distal LAD has mild luminal irregularities but it is free of angiographically evident flow-limiting disease.
CONCLUSIONS:
1. Subtotal stenosis of the mid Lad with a patent LIMA to the mid LAD.
2. Chronic total occlusion of the circumflex vessel with occlusion of the vein graft to the circumflex.
3. Chronic total occlusion of the right with a patent vein graft to the right coronary artery.
PLAN: The plan at this time will be to continue to optimize anti-anginal medications. We will have the patient be observed overnight due to the multiple arterial sticks. We will also have the patient follow up in my office as scheduled. We will consider EECP in this patient in the future.
***************
I am thinking only 93459, but can the doctor be reimbursed for the two different accesses (radial and Femoral)?
Thanks for any help!
1. Left heart catheterization with selective right and left coronary angiography via left common femoral approach.
2. Selective left internal mammary angiography to the LAD via left radial approach.
INDICATIONS FOR PROCEDURE: This patient is presenting with increasing anginal symptoms despite medical therapy and an abnormal Cardiolite stress test.
COMPLICATIONS: None.
TOTAL CONTRAST: 80 mL.
DESCRIPTION OF PROCEDURE: The patient was brought to the cath lab after informed and signed consent was obtained. The left radial area was draped and prepped in a sterile surgical fashion. The right inguinal area was draped and prepped in a sterile surgical fashion. Vascular access was obtained in the left radial artery with a long 6-French hydrophilic sheath.
Using 5-French diagnostic TIG catheter, I attempted tried to cannulate the left main but was unsuccessful due to the tortuosity. I also was not able to cannulate the right coronary artery. I was able to cannulate the vein graft to the circumflex vessel. This catheter has been repositioned in the subclavian artery and selective left internal mammary artery angiography to the LAD was performed. This catheter was then removed.
Vascular access was then obtained through the left common femoral artery with a 6-French introducer sheath. Using a 5-French 3.5 JL4 diagnostic catheter, the left main was cannulated and left coronary angiography were then performed in orthogonal views. This catheter was removed and exchanged for a 5-French JR4 diagnostic catheter. It was placed in the right
coronary ostium and right coronary angiography was then performed. This catheter was then repositioned into the vein graft to the right coronary artery and again vein graft angiography to the right coronary artery was also performed. Note that while the TIG catheter was in place, it was placed across the aortic valve. Hemodynamics were obtained including pullback
pressures.
FINDINGS:
1. The left main is a relatively large vessel that does have superficial calcification. It gives rise to a left anterior descending and left circumflex system and is free of significant stenosis.
2. The left circumflex vessel has a very high obtuse marginal vessel that is a 1.5+ mm vessel and has mild luminal irregularities. It course out toward the lateral apical segment. The circumflex artery itself terminates, is occluded in its proximal segment.
3. The left anterior descending artery has diffuse calcification present throughout its proximal segment. It gives rise to a very large diagonal vessel that has a diffuse 55% stenosis. The LAD itself in the mid segment has a subtotal stenosis. There is competitive flow visualized from the LIMA graft.
4. The right coronary artery is occluded in its proximal segment.
5. Vein graft to the right coronary artery is patent. It inserts on the distal RCA. The PDA is a relatively small vessel with diffuse atherosclerotic disease.
6. The vein graft to the circumflex is occluded in its proximal segment.
7. The LIMA to the LAD is widely patent. It inserts on the mid LAD. The mid and distal LAD has mild luminal irregularities but it is free of angiographically evident flow-limiting disease.
CONCLUSIONS:
1. Subtotal stenosis of the mid Lad with a patent LIMA to the mid LAD.
2. Chronic total occlusion of the circumflex vessel with occlusion of the vein graft to the circumflex.
3. Chronic total occlusion of the right with a patent vein graft to the right coronary artery.
PLAN: The plan at this time will be to continue to optimize anti-anginal medications. We will have the patient be observed overnight due to the multiple arterial sticks. We will also have the patient follow up in my office as scheduled. We will consider EECP in this patient in the future.
***************
I am thinking only 93459, but can the doctor be reimbursed for the two different accesses (radial and Femoral)?
Thanks for any help!
