Answer Carotid/cerebral angiogram with SCA angiogram and Abdominal angiogram!

carelitz

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Just looking to double check my work. Thanks for any insights!

The codes i came up with are:

36223 50 (bilateral carotid and cerebral angiogram)
36215 59 (cath placement to the proximal left subclavian artery)
75710 2659LT (left subclavian artery angiogram)

75625 2659 (abdominal angiogram)


PROCEDURES PERFORMED:

1. Bilateral carotid, and cerebral angiogram.
2. Selective left subclavian artery angiogram.
3. Aortic catheter placement.
4. Distal aortic angiogram.

INDICATIONS FOR PROCEDURE: This is a lady who had worsening
carotid disease by noninvasive evaluation, and because of also suggested
intracranial carotid disease, the angiogram was indicated. The patient
does have history of known stable peripheral vascular disease, although
does report worsening left leg claudication lately. Pros and cons of
procedure were discussed in many details, consent was obtained.

With initial access to the right femoral artery, we had difficulties
advancing the wire through the proximal right iliac artery, hence distal
abdominal aortic angiogram was obtained to evaluate progression of
peripheral vascular disease.

TECHNIQUE: Vascular access obtained to the right common femoral artery
with micropuncture kit in modified Seldinger technique, and 5-French
sheath was introduced. Heparin 3000 units given intraarterial upon sheath
insertion.

The 5-French JR4 catheter was used for selective angiogram of the
innominate artery, and right carotid artery, and was selectively placed
first to the innominate artery, and then to the proximal right common
carotid artery with the support of Versacore wire. Then, same catheter
was navigated to the proximal left subclavian artery and used for left
subclavian artery angiogram.

For the right carotid angiogram, a 5-French 3DRC catheter was used and
selectively placed to the proximal left common carotid artery.

For the distal aortogram, the 3DRC catheter was placed to the distal aorta
above the bifurcation, and angiogram obtained. The cervical carotid
angiogram was obtained in orthogonal views bilaterally. The cerebral
angiogram was obtained in lateral and Towne views bilaterally. The left
subclavian angiogram was obtained in AP projection, so was a distal view
of the left vertebral angiogram, which was nonselective from the left
subclavian.

The abdominal aortogram was obtained in AP projection.

Manual management of access site was provided.

Procedure was performed with local anesthesia only with 15 mL of 2 percent
lidocaine to the right groin.

The patient also received premedication for KNOWN IV DRUG ALLERGY per
protocol.

The blood loss was insignificant, there were no immediate complications.
The sheath was pulled in the cath lab and manually managed.

HEMODYNAMICS: Arterial pressure was 155/70 mmHg in the aorta and 142/60
mmHg in the right femoral artery, suggestive of 15 mmHg gradient across
stenosis in the right iliac artery.

INNOMINATE ARTERY ANGIOGRAM:

1. Innominate artery is a large vessel taken off the type 2 calcified
aortic arch, there is about 20 percent ostial stenosis
insignificant. Vessel then gives a large subclavian artery, which
has about 40 percent proximal stenosis, nonobstructive. There is
medium size vertebral artery taken off subclavian artery with
antegrade flow. There is also right internal mammarian artery well
visualized.
2. Right common carotid artery takes off from the innominate artery.
3. Right carotid artery angiogram including cervical and cerebral
views: Right common carotid artery is a large vessel. The proximal
and midportion has no significant stenosis. The distal portion has
40 percent stenosis, and then immediately prior to the bifurcation,
there is an 80 percent stenosis, which involves bifurcation.
4. The right external carotid artery is a medium-sized vessel with 95
percent ostial stenosis.
5. Right internal carotid artery is a large vessel. There is 80
percent ostial stenosis, which is continuation of the bifurcation
disease, and the rest of the cervical right carotid artery has no
evidence of significant stenosis, but mild luminal irregularities.
6. The intracranial portion of the right internal carotid artery has
moderate luminal irregularities, but not more than 50 percent
stenosis I cannot also rule out very small aneurysmal dilatations of
the artery, but there is no evidence of significant aneurysm or mobile plaque or thrombus.
7. The right internal carotid artery gives rise to the medium size mid
cerebral artery, which has mild luminal irregularities, but no
significant stenosis, and then the right anterior cerebral artery,
which is a medium-sized vessel and shows no evidence of significant
stenosis.

LEFT CAROTID ARTERY ANGIOGRAM.

1. Left common carotid artery is a large vessel, taken with a sharp
angle from type 2 aortic arch. The midportion of the vessel has
moderate luminal irregularities, 30 percent stenosis. The distal
portion has about 50 percent stenosis, which then continues into the
internal carotid artery stenosis, and external carotid artery
stenosis.
2. Left external carotid artery is a medium-sized vessel with 50
percent ostial stenosis.
3. Left internal carotid artery, the cervical portion. The ostial
portion of the vessel has 90 percent stenosis with significantly
calcified plaque. The mid distal cervical carotid artery has about
40 percent stenosis without mobile or ulcerated plaque,
nonobstructive.
4. The intracranial portion of the left internal carotid artery has
sequential 50 percent and 60 percent stenosis, this does not appear
to be obstructive. The vessel then gives rise to the medium size
left mid cerebral artery, which has no evidence of significant
stenosis, and medium size left anterior cerebral artery, which has
no evidence of significant stenosis.
5. On additional note, the venous phase of the cerebral angiogram
showed no evidence of abnormalities.

LEFT SUBCLAVIAN ARTERY ANGIOGRAM

1. Left subclavian artery is a large vessel, which has about 40 percent
stenosis in the mid segment of the proximal portion. Then, vessel
gives large dominant vertebral artery, which appears patent with
brisk antegrade flow supplying basilar artery and in turn posterior
cerebral arteries. The left internal mammarian artery is patent.
The mid distal left subclavian artery has no evidence of significant
stenosis.

DISTAL AORTA, AND BILATERAL ILIAC ANGIOGRAM: Again, this angiogram was
obtained because of known peripheral vascular disease, and difficulties
crossing the iliac artery with initial approach.

Distal aorta is heavily calcified with moderate plaque, but no obstructive
disease, no evidence of aneurysm.


Right:

1. Common iliac artery is a medium large vessel with ostial 60 percent
calcified stenosis.
2. Hypogastric artery is a large vessel without evidence of significant
stenosis.
3. External iliac artery is a medium-sized vessel with moderate about
50 percent proximal stenosis.
4. Common femoral artery is a medium-sized vessel with about 80 percent
calcified mid portion stenosis, the visible portion of the proximal
right deep femoral artery is widely patent, the proximal right
superficial femoral artery has 70 percent calcified stenosis.

Left:

1. Common iliac artery is a medium size calcified vessel with 95
percent ostial stenosis, and 80 percent proximal-mid portion
stenosis.
2. Hypogastric artery was not clearly visualized, but appears to be of
medium size with decreased flow.
3. External iliac artery is a medium-large size vessel without
significant stenosis.
4. The left common femoral artery is a medium-sized vessel with about
30 percent midportion stenosis.

CONCLUSIONS:

1. Severe bilateral cervical carotid artery disease.
2. Right common carotid/internal carotid artery 80 percent stenosis,
external carotid artery 95 percent stenosis.
3. Left distal common carotid artery 50 percent stenosis, ostial
proximal internal carotid artery 90 percent stenosis, external
carotid artery 50 percent stenosis.
4. Moderate intracranial internal carotid artery disease with 50
percent stenosis of the right intracranial internal carotid artery,
and 50-60 percent stenosis of the left and intracranial carotid
artery. For intracranial carotid artery disease, recommend medical
therapy.
5. Severe peripheral vascular disease with 60-70 percent stenosis of
the right ostial common iliac artery, 95 percent stenosis of the
left common iliac artery, 80 percent stenosis of the right mid
common femoral artery.
 

Jim Pawloski

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I come up 36223-50 for the carotids, 36225-LT for the left vertebral ( catheter placement in subclavian) and 75716 for the lower extremity angio.
HTH,
Jim Pawloski, CIRCC
 

carelitz

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I come up 36223-50 for the carotids, 36225-LT for the left vertebral ( catheter placement in subclavian) and 75716 for the lower extremity angio.
HTH,
Jim Pawloski, CIRCOh interesting, thanks Jim! Can you help me understand why the 36225? I see it does say cath placement in the subclavian artery. That make sense. But did he angiography of the vertebral circulation? Is the subclavian part of that? ie

Thanks Jim! I see now where he states, " The left subclavian angiogram was obtained in AP projection, so was a distal view of the left vertebral angiogram, which was nonselective from the left
subclavian." So that I understand is the subclavian angiogram as well as cath placement for that included in the code 36225? So that would eliminate my codes choices:
36215 59 (cath placement to the proximal left subclavian artery) AND 75710 2659LT (left subclavian artery angiogram) in favor of 36225.

I see in the conclusions regarding the LT and RT iliacs for the 75716 from where he states, "DISTAL AORTA, AND BILATERAL ILIAC ANGIOGRAM: Again, this angiogram was obtained because of known peripheral vascular disease, and difficulties crossing the iliac artery with initial approach."


What about the 75625 for "The abdominal aortogram was obtained in AP projection." ?

Thanks for your help, i am still learning these and really appreciate your help!
 
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