em2177
Expert
NEED HELP CODING THIS REPORT. WOULD THIS BE CORRECT: 93458,92980,92996???
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 81-year-old
gentleman who has severe cardiomyopathy, status post defibrillation. The
patient has severe coronary artery disease. The patient has had progressive
unstable angina. Angiography recently showed total occlusion of the LAD with a
patent SVG to the LAD and severe RCA with a total occlusion that was chronic
with an SVG to the distal RCA. There is no graft to the left circumflex, and
ostially there is a heavily calcified 80% to 90% lesion in the ostial segment.
Due to this, we have explained the risks, benefits, and alternatives to
Rotablator plus or minus angioplasty and stenting, and the patient is eager to
proceed.
PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion Lidocaine was placed to the right common femoral
area using standard technique, and a 6-French sheath was placed to the right
common femoral artery using Seldinger technique.
Left heart catheterization was performed. A 7-French short sheath was placed
via Seldinger technique. Angiography was performed with a 7-French XB 3.5
guide catheter. At this point, the Rotablator apparatus was prepped in a
standard fashion and calibrated. Then a RotaWire floppy extra-support wire was
placed into the distal obtuse marginal branch. Then Rotablator was placed to
the distal left main, and then serial runs of Rotablator with a 1.25 bur was
performed over the ostial to proximal left circumflex with a good polishing run
at the end. The Rotablator was removed using Dynaglide and then removed. At
this point, a 3.0 x 15 Apex balloon was placed into the proximal portion of the
obtuse marginal. The RotaWire was removed, and an S'port wire was placed
distally. Next the balloon was brought back to the ostial/proximal segment of
the left circumflex, and re-dilatation was performed to 12 atmospheres. Repeat
angiography was performed, and nitroglycerin 100 meg was given. At this point,
stenting with a 3.5 x 16 Promus Element drug-eluting stent was placed at the
ostial of the left circumflex just distal to a ramus branch and the distal
segment was proximal to the obtuse marginal 1 branch. This was inflated to 14
atmospheres. The STS system was brought back. Nitroglycerin was given.
Repeat angiography in multiple views was performed. The wire was removed, and
the catheter was removed.
Angiography of the groin was performed, and an Angio-Seal 8-French was placed
per standard protocol with good groin hemostasis; no evidence of oozing,
bruising, or hematoma. The patient received weight-based heparin throughout
the procedure. The patient has been chronically on aspirin and Effient
therapy. I reviewed the findings with him.
IMPRESSION:
1. Left main has no significant disease.
2. The LAD has an ostial occlusion but has an SVG. The ramus branch is patent
with a proximal 40% to 60% lesion.
3. The left circumflex in the ostial segment is heavily calcified, 80% to 90%,
status post 1.25 Rotablator bur and PTCA followed by 3.5 x 16 Promus
drug-eluting stent with TIMI-3 flow with 0% residual stenosis.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 81-year-old
gentleman who has severe cardiomyopathy, status post defibrillation. The
patient has severe coronary artery disease. The patient has had progressive
unstable angina. Angiography recently showed total occlusion of the LAD with a
patent SVG to the LAD and severe RCA with a total occlusion that was chronic
with an SVG to the distal RCA. There is no graft to the left circumflex, and
ostially there is a heavily calcified 80% to 90% lesion in the ostial segment.
Due to this, we have explained the risks, benefits, and alternatives to
Rotablator plus or minus angioplasty and stenting, and the patient is eager to
proceed.
PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion Lidocaine was placed to the right common femoral
area using standard technique, and a 6-French sheath was placed to the right
common femoral artery using Seldinger technique.
Left heart catheterization was performed. A 7-French short sheath was placed
via Seldinger technique. Angiography was performed with a 7-French XB 3.5
guide catheter. At this point, the Rotablator apparatus was prepped in a
standard fashion and calibrated. Then a RotaWire floppy extra-support wire was
placed into the distal obtuse marginal branch. Then Rotablator was placed to
the distal left main, and then serial runs of Rotablator with a 1.25 bur was
performed over the ostial to proximal left circumflex with a good polishing run
at the end. The Rotablator was removed using Dynaglide and then removed. At
this point, a 3.0 x 15 Apex balloon was placed into the proximal portion of the
obtuse marginal. The RotaWire was removed, and an S'port wire was placed
distally. Next the balloon was brought back to the ostial/proximal segment of
the left circumflex, and re-dilatation was performed to 12 atmospheres. Repeat
angiography was performed, and nitroglycerin 100 meg was given. At this point,
stenting with a 3.5 x 16 Promus Element drug-eluting stent was placed at the
ostial of the left circumflex just distal to a ramus branch and the distal
segment was proximal to the obtuse marginal 1 branch. This was inflated to 14
atmospheres. The STS system was brought back. Nitroglycerin was given.
Repeat angiography in multiple views was performed. The wire was removed, and
the catheter was removed.
Angiography of the groin was performed, and an Angio-Seal 8-French was placed
per standard protocol with good groin hemostasis; no evidence of oozing,
bruising, or hematoma. The patient received weight-based heparin throughout
the procedure. The patient has been chronically on aspirin and Effient
therapy. I reviewed the findings with him.
IMPRESSION:
1. Left main has no significant disease.
2. The LAD has an ostial occlusion but has an SVG. The ramus branch is patent
with a proximal 40% to 60% lesion.
3. The left circumflex in the ostial segment is heavily calcified, 80% to 90%,
status post 1.25 Rotablator bur and PTCA followed by 3.5 x 16 Promus
drug-eluting stent with TIMI-3 flow with 0% residual stenosis.