Wiki Aortic Stent with lots of imaging, detailed report

carelitz

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There's a lot going on here and some help would be appreciated. Here is what i have come up with:

93458 26 Left heart cath
93567 Supravalvular aortography
37252 RT IVUS Aorta
37253 LT IVUS Iliac
36225 Subclavian with vertebral circulation angiogram
75630 2659 Abdominal aortogram
37236 Stent in aorta
75736 Selective hypogastric (internal iliac) angiogram




PROCEDURES PERFORMED:
1. Left heart catheterization and selective coronary angiogram.
2. Supravalvular aortogram.
3. Selective left subclavian angiogram.
4. Abdominal aortogram.
5. Intravascular ultrasound of aorta and left iliac artery.
6. Abdominal aorta percutaneous transluminal angioplasty and 11 x 29 mm
VBX stent, dilated to 12 mm.

INDICATIONS FOR PROCEDURE: This is a patient who developed
Takayasu arteritis. She was initially treated with steroids with moderate
deficiency. She then developed severe bilateral claudication, had
abnormal duplex ultrasound suggestive of proximal disease, followed by CTA
of aorta, which suggested high-degree distal aortic stenosis. She also
had symptoms of significant angina, and left arm claudication with
decreased pulses. Pros and cons of procedure were discussed in many
details, and consent was obtained.

TECHNIQUE: Left common femoral artery access was obtained with ultrasound
guidance in modified Seldinger technique with the use of micropuncture
kit, and initially 6-French 45 cm destination sheath was introduced and
with the support of 260 Versacore wire was advanced through the stenosis
in the aorta to the descending thoracic aorta and used for initial
angiograms.

A 5-French pigtail catheter was used for crossing the aortic valve and
left ventriculogram, which was performed in RAO projection with power
injection of 15 mL of contrast.

Pullback was performed and pressure measurements were performed.

Same pigtail catheter was used for the supravalvular aortogram, which was
performed in 35-degree LAO projection.

Same pigtail catheter was then pulled back to the abdominal aorta
immediately proximal to the origin of renal arteries and abdominal
aortogram was performed in AP projection with power injection of 20 mL of
contrast.

Selective left subclavian angiogram was performed due to the patient's
left arm symptoms with 5-French JR4 catheter positioned to the proximal
left subclavian artery in AP projection.

Selective coronary angiogram was performed with 5-French JL3.5, and
5-French JR4 catheter with a standard technique.

For the interventional part of the aortic stent, the sheath was exchanged
to the 8-French 45 cm Destination sheath positioned to the mid left common
iliac artery.

An 8-French Phillips intravascular ultrasound probe was used for the
ultrasound, which was advanced over the 300 cm SupraCore wire to the
descending aorta, pullback was performed through entire abdominal aorta,
and then to the left common iliac artery, images were obtained and
analyzed. The intravascular ultrasound was performed immediately after
stent deployment, and after the stent post dilatation.

Perclose closure device was successfully deployed to the left common
femoral artery upon completion of the procedure.

Local anesthesia was used with 2 percent lidocaine, 20 mL to the left
groin.

Anticoagulation was provided with IV heparin during the procedure with ACT
of 254, the patient is already on dual antiplatelet therapy with aspirin
and Plavix prior to the procedure. Additional Plavix 150 mg was given.

Blood loss was 15 mL with blood samples taken for ACT measurements.

Moderate sedation was provided throughout the procedure with IV Versed in
a total dose of 3 mg and fentaNYL in a total dose of 100 mcg injected by
RN nurse in my presence and under my direct supervision. The EKG, blood
pressure, O2 saturation was continuously monitored. The sedation time was
1 hour 15 minutes.

HEMODYNAMICS:
1. LV pressure was 115/0/8 mmHg. LVEDP was 8 mmHg.
2. Aortic pressure in the ascending aorta and thoracic aorta was 118/70
mmHg. There was no LV to aorta gradient.
3. The aortic pressure in the distal abdominal aorta beyond the
stenosis was 88/45 mmHg. There was 27 mmHg gradient through the
lesion in distal aorta.

LEFT VENTRICULOGRAM: Left ventricle is of normal size with normal
systolic function, ejection fraction 60 percent without wall motion
abnormalities.

SELECTIVE CORONARY ANGIOGRAM:
1. Right dominant circulation.
2. Left main is a large short vessel without any evidence of stenosis
including no ostial stenosis.
3. LAD is a medium-sized vessel, gives medium-sized distal diagonal
branch, the vessel has no obstructive stenosis.
4. Circumflex is a medium size, nondominant vessel, gives medium size
OM1, which has sub-branches and small OM2. Vessel has no stenosis.
5. RCA is a medium to large dominant vessel, gives medium large RPL,
small RPDA, vessel has no evidence of obstructive stenosis.

SUPRAVALVULAR AORTOGRAM:
1. Ascending aorta and aortic root appears of normal size without
evidence of aneurysm, dissection, or any significant plaque. There
is no evidence of aortic regurgitation.
2. Aortic arch is normal sized type 1 arch. No evidence of aneurysm,
dissection, or any plaque.
3. Descending thoracic aorta in the visualized portion is normal size
vessel without evidence of coarctation, dissection, aneurysm or
stenosis.
4. The proximal great vessels were well visualized. There is large
innominate artery, which has no evidence of any stenosis, which
gives rise to large right common carotid artery and right subclavian
artery, which has no evidence of stenosis.
5. The left common carotid artery, takes off immediately distal from
the innominate, and has no evidence of any significant stenosis.
6. Left subclavian artery is a large vessel, which has no stenosis in
the proximal portion, but the mid distal portion was not well
visualized on nonselective picture.

LEFT SUBCLAVIAN ARTERY ANGIOGRAM: Left subclavian artery was cannulated
with a JR4 5-French catheter positioned to the proximal portion of the
vessel in AP projection and angiogram obtained. Left subclavian artery is
a large vessel. There is no evidence of stenosis in proximal, mid or
distal portion. On angiogram, there is no evidence of compression of the
vessel. The visible portion of the proximal axillary artery is also fully
patent. Vessel gives rise to the large left vertebral artery, which has no
stenosis and has brisk antegrade flow. The left artery was also
well visualized, and is fully patent.

ABDOMINAL AORTOGRAM: Abdominal aorta is medium-small size vessel, the
suprarenal portion gives rise to celiac trunk, SMA artery. Right and left
renal arteries with left renal artery is substantially lower than the
right and then in the distal portion about 4 cm above the bifurcation,
there is a severe stenosis, which angiographically looks at least 80
percent. This is a short stenosis.

The visible right common iliac artery is a medium-sized vessel without
significant stenosis.

The right hypogastric artery is a medium-sized vessel without stenosis.

Proximal right external iliac artery is a large vessel without stenosis.

Left common iliac artery is a large vessel with mild luminal
irregularities, but no significant stenosis. The left hypogastric is a
medium-sized vessel without significant stenosis. The left external iliac
artery is a medium-sized vessel with mild luminal irregularities, but no
significant stenosis.

INTRAVASCULAR ULTRASOUND FINDINGS OF THE DISTAL AORTA AND LEFT COMMON
ILIAC ARTERY: Once severe stenosis of distal aorta was confirmed, we
proceeded with intervention, and intravascular ultrasound was performed to
accurately measure the stenosis.

We exchanged the pigtail catheter to the 300 cm SupraCore wire advanced to
the aortic arch, and then advanced 0.035 IVUS catheter to the proximal
abdominal aorta and performed pullback with images recorded. It showed
focal severe 93 percent area of stenosis of the distal aorta with fibrotic
plaque and evidence of some organized thrombus; however, proximal and
distal to the stenosis, the aorta was clean. The measured diameter
proximally was 11.5 mm and distally 12 mm.

Left common iliac artery was 6.6 x 7.5 mm vessel with no significant
obstructive plaque seen.

ANGIOPLASTY AND STENT OF THE DISTAL AORTA. Once we confirmed location and
severity of the lesion, we positioned 11 x 29 mm VBX covered stent across
the lesion and deployed it at nominal 11 atmospheres for 1 minute, then
the deployment balloon was removed and we performed IVUS, which showed
well alignment of the proximal portion, but minimal under expansion of the
distal portion of the stent considering the size of the aorta, so we
placed a 12 x 20 mm balloon within the stent, and performed post
dilatation at nominal 4 atmospheres for another 30 seconds and then 5
atmospheres in the distal portion for another 40 seconds. Balloon was then
removed, and another IVUS performed, which showed excellent stent
alignment, apposition and full expansion with 1:1 ratio to the aorta. No
evidence of any dissection.

The IVUS catheter was removed. We again placed 5-French pigtail catheter
to the abdominal aorta above the stent and performed final angiogram,
which showed excellent stent expansion and apposition, 0 percent stenosis
residually, excellent brisk flow, no dissection, no extravasation. No complications.
 
Last edited:
For the left subclavian artery imaging, you need to code 36215-LT and 75710-LT,59. For 75736, there is no documentation of a catheter placed into the internal iliac artery. Delete 75736.
HTH,
Jim Pawloski, CIRCC
 
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