mcdeleon
New
Any help is appreciated! This is new to our practice.
We have: 36222 50 and +36227 50
We are being told to look at 36223 50
PROCEDURES PERFORMED:
INDICATIONS FOR THE PROCEDURE: This is a 65-year-old gentleman with a known history of dyslipidemia, hypertension, coronary artery disease with history of previous PCI and carotid disease, who had an ultrasound evidence of progression of left carotid artery stenosis to severe. The patient had abnormal nuclear stress test suggestive of fixed inferior wall defect. Pros and cons of procedure were discussed, consent was obtained.
Allen's test on the right was normal.
TECHNIQUE: Arterial access obtained to the right radial artery with a modified Seldinger technique and 6-French glide sheath introduced.
Verapamil 2.5 mg and heparin 4000 units given intraarterial upon sheath insertion. The 6-French JR4 catheter was used for left heart catheterization and pressure measurements, the patient has known normal LV function, no LV gram was performed, pullback of the catheter through the aortic valve was performed.
A 6-French JR4 catheter was used for selective angiogram of the right coronary artery with standard technique and same catheter was used to selectively engage right common carotid artery for right carotid artery angiogr am .
The 6-French JL4 catheter was used for selective angiogram of the left coronary artery with standard technique and same catheter was used to selectively engage the left common carotid artery and performed the left carotid angiogram.
The local anesthesia performed with 2 percent lidocaine, 2 mL to the right wrist.
Moderate sedation with IV Versed and fentaNYL of 1 mg and 50 mcg respectively.
Blood loss was negligible.
TR band successfully deployed to the right wrist upon completion of the procedure.
HEMODYNAMICS:
RIGHT CAROTID ANGIOGRAM:
The patient needs revascularization of the left internal carotid artery and considering high location of the stenosis, he has high risk anatomical features and in my opinion, it will be better served with angioplasty and stent with distal embolic protection. We will discuss these findings with the patient. He will be offered vascular surgery evaluation to, but most likely will need stent procedure in the near future. Should he need stent procedure, he will be on dual antiplatelet therapy with aspirin and Plavix and stent o the eft carotid artery will need to be performed from the femoral approach with 8-10 x 40 mm stent and distal embolic protection.
We have: 36222 50 and +36227 50
We are being told to look at 36223 50
PROCEDURES PERFORMED:
- Left heart catheterization, selective coronary angiogram.
- Selective bilateral cervical carotid angiogram.
INDICATIONS FOR THE PROCEDURE: This is a 65-year-old gentleman with a known history of dyslipidemia, hypertension, coronary artery disease with history of previous PCI and carotid disease, who had an ultrasound evidence of progression of left carotid artery stenosis to severe. The patient had abnormal nuclear stress test suggestive of fixed inferior wall defect. Pros and cons of procedure were discussed, consent was obtained.
Allen's test on the right was normal.
TECHNIQUE: Arterial access obtained to the right radial artery with a modified Seldinger technique and 6-French glide sheath introduced.
Verapamil 2.5 mg and heparin 4000 units given intraarterial upon sheath insertion. The 6-French JR4 catheter was used for left heart catheterization and pressure measurements, the patient has known normal LV function, no LV gram was performed, pullback of the catheter through the aortic valve was performed.
A 6-French JR4 catheter was used for selective angiogram of the right coronary artery with standard technique and same catheter was used to selectively engage right common carotid artery for right carotid artery angiogr am .
The 6-French JL4 catheter was used for selective angiogram of the left coronary artery with standard technique and same catheter was used to selectively engage the left common carotid artery and performed the left carotid angiogram.
The local anesthesia performed with 2 percent lidocaine, 2 mL to the right wrist.
Moderate sedation with IV Versed and fentaNYL of 1 mg and 50 mcg respectively.
Blood loss was negligible.
TR band successfully deployed to the right wrist upon completion of the procedure.
HEMODYNAMICS:
- Arterial pressure was 140/80 mmHg.
- Left ventricular pressure was 140/2/15 mmHg, LVEDP was 15 mmHg.
- There was no LV to aorta gradient.
- Right dominant circulation.
- Left main is a medium size short vessel without evidence of significant stenosis.
- LAD is a medium-sized vessel with moderate diffuse plaque, there is 40-50 percent proximal stenosis, there is 55 percent midportion stenosis, but there is no evidence of obstructive lesions, vessel gives medium size diagonal branch, which has no evidence of significant stenosis.
- There is medium size long ramus intermedius artery, which has about
- The circumflex is a medium size, nondominant vessel continues in small medium size OM. There is a patent stent within the mid circumflex and continuing into the OM with a mild 30-40 percent restenosis. Proximally to the stent, there is about 50 percent stenosis.
- RCA is a medium-large size dominant vessel, which has anterior inferior takeoff. There is a proximal loop, but no significant stenosis. The vessel has mild luminal irregularities, not more than
RIGHT CAROTID ANGIOGRAM:
- Right common carotid artery is a large vessel, taken off innominate artery and has no evidence of stenosis.
- Right external carotid artery is a medium-sized vessel without evidence of any significant stenosis.
- Cervical right internal carotid artery has about 20 percent stenosis in the area of carotid bulb, which is insignificant, no significant plaque or mobile plaque with the rest of right cervical internal carotid artery had no significant stenosis and brisk antegrade flow.
- Left common carotid artery takes off from type 2 aortic arch. There was incidental finding of left originated from aortic arch
- Left common carotid artery has no evidence of stenosis.
- Left external carotid artery is a medium-sized vessel without stenosis.
- Left internal carotid artery is a vessel. The bulb of the left internal carotid artery has no significant stenosis, but immediately transitioned to the proximal-mid portion of the cervical left internal carotid artery, there is 80 percent stenosis. The rest of the cervical left internal carotid artery has no evidence of significant disease.
- Coronary artery disease, 50 percent proximal circumflex stenosis followed by patent stent, 40-50 percent proximal LAD stenosis, 55 percent mid LAD stenosis, 40-50 percent ramus intermedius stenosis.
- Normal LVEDP, no LV to aorta gradient.
- Significant 80 percent stenosis of the left internal carotid artery with anatomically high location of the stenosis at the transition from the carotid bulb to the mid left internal carotid artery.
- No evidence of significant stenosis of the right internal carotid artery.
The patient needs revascularization of the left internal carotid artery and considering high location of the stenosis, he has high risk anatomical features and in my opinion, it will be better served with angioplasty and stent with distal embolic protection. We will discuss these findings with the patient. He will be offered vascular surgery evaluation to, but most likely will need stent procedure in the near future. Should he need stent procedure, he will be on dual antiplatelet therapy with aspirin and Plavix and stent o the eft carotid artery will need to be performed from the femoral approach with 8-10 x 40 mm stent and distal embolic protection.