empalagiglass
Contributor
Procedure Date: 11/11/2020
Pre-Operative Diagnosis: STEMI
STEMI (7 days)
Typical Angina CCS 4
None
Post Operative Diagnosis:
1. Spontaneous coronary artery dissection of distal LAD with 100% occlusion
2. Spontaneous coronary dissection with intramural hematoma in left main and LAD
3. Cardiogenic shock
4. Angiography of the right external iliac artery is highly suggestive of fibromuscular dysplasia.
5. Swan Gantz catheter placement at the right IJ
6. Impella CP placement from left femoral artery
7. Impella RP placement from the right femoral vein
8. Intravascular ultrasound of left main and entire LAD
9. Intravascular ultrasound of the right and left external iliac arteries
Procedure Performed: DIAGNOSTIC LEFT HEART CATH POSS PCI
-Right heart catheterization
-Leave in Swan placement
-Impella CP placement from left femoral artery
-Impella RP placement from the right femoral vein
-Intravascular ultrasound of left main and entire LAD
- Intravascular ultrasound of the right and left external iliac arteries
Date of Procedure: 11/11/2020
Type of Anesthesia Used: Moderate Sedation
Access site:
Artery: right radial artery right femoral artery, left femoral artery
Vein: right internal jugular vein, right femoral vein
Catheters:
6F IKari 3.5
Description of Findings:
Right dominant system
LM: Mid left main has 60 to 70% stenosis likely due to intramural hematoma.
LAD: Proximal and mid LAD appears normal but tortuous.
-Diagonal 1 is normal
-Distal LAD has an acute band and it is occluded 100% due to spontaneous coronary artery dissection (SCAD)
LCX: Normal, OM1 normal
RCA: Normal
Grafts:
LV-gram: Not performed
LVEDP: 20 mmHg
Procedure details:
Patient was emergently brought to the cardiac catheterization lab. Right wrist and bilateral groins were prepped and draped in standard sterile fashion. 2% lidocaine was infiltrated into the right wrist. Then right radial artery access was obtained using modified Seldinger technique. Then right coronary angiography was performed using IKari 3.5 guide catheter.
LVEDP was measured with the same catheter. Then left coronary angiography was performed with Ikari 3.5 guide catheter
PCI: Due to patient's severe symptoms of 10 out of 10 chest pain, and anatomy suggestive of spontaneous coronary artery dissection decision was made to attempt to perform PCI of distal LAD.
A prowater coronary guidewire was carefully navigated into the mid LAD however it was not able to go into the distal LAD. Then a second run-through coronary guidewire was carefully navigated and after some difficulty we were able to advance the wire into distal LAD. Then intravascular ultrasound catheter was advanced into distal LAD and images were obtained via pullback method from distal LAD to left main. IVUS images showed large circumferential intramural hematoma in mid left main extending into proximal LAD.
As patient became more and more agitated and hemodynamically unstable, decision was made to access right femoral artery.
2% lidocaine was infiltrated into right femoral area and with the use of ultrasound guidance, right femoral artery access was obtained using modified Seldinger technique.
Femoral angiography showed classic beaded appearance of right external iliac artery highly suggestive of fibromuscular dysplasia. Then intravascular ultrasound was performed of this right femoral and external iliac artery which showed inadequate lumen diameter to accommodate 14 French Impella sheath. Then a IMA guide catheter was advanced and left sided external iliac and femoral angiography was performed. Intravascular ultrasound was then performed on the left sided external iliac and femoral artery.
IVUS measurements were adequate for Impella placement. Then Impella CP was placed without any difficulty.
Then 2% lidocaine was infiltrated into right neck and with the use of ultrasound guidance right IJ was accessed and right heart catheterization was performed. Then Swan-Ganz catheter was left into the pulmonary artery for hemodynamic monitoring.
As patient became more and more agitated and her pain was uncontrollable, anesthesia team was called and patient was electively intubated.
During this time, heart team approach was considered and emergent consult with CT surgery was made. After careful discussion, conservative management was recommended with hemodynamic support.
Then after careful discussion decision was made to perform Impella RP placement.
Then 2% lidocaine was infiltrated into right femoral area and right femoral vein access was obtained using modified Salinger technique. Then a 23 French Impella RP sheath was placed without difficulty. On a second timeout, it was discovered that the RP Impella was expired. So so urgent phone calls were made and the nearest RP Impella was available in Bryan Lincoln Hospital. Device rep for Impella RP decided to bring Impella from Bryan Lincoln Hospital. During this time with The patient hemodynamically stable with left-sided Impella CP.
After the Impella RP became available the previously placed 23 French sheath was exchanged and a new sheath was placed. Then Impella RP was placed with the use of balloontipped Swan catheter guidance. Position of Impella RP was confirmed and hemodynamic support was initiated.
Post both Impella S placement, the run-through coronary guidewire was carefully withdrawn and left main coronary guide was disengaged. The guide was then exchanged with a 5 French pigtail catheter and nonselective root angiography was performed which showed no evidence of left main dissection and TIMI I flow in the distal LAD which was previously 100% occluded.
At the end of the case cardiac output was 2.9 L/min on Impella CP and Impella RP.
Throughout the case ACT of more than 250 was maintained with the heparin.
We will start the patient on IV heparin drip.
Closure device: TR Band placement at right radial artery access site.
-Leave in Swan placement right IJ
-Leave in Impella CPin the left femoral artery
-Leave in Impella RP in the right femoral vein
Estimated Blood Loss: Minimal
Specimen(s) Removed: None
Contrast: 245 ml
Radiation dose: 667 mGy
Complications: Transcutaneous bi-ventricular hemodynamic support was placed
Summary:
1. Spontaneous coronary artery dissection of distal LAD with 100% occlusion
2. Spontaneous coronary dissection with intramural hematoma in left main and LAD
3. Cardiogenic shock
4. Angiography of the right external iliac artery is highly suggestive of fibromuscular dysplasia.
5. Swan Gantz catheter placement at the right IJ
6. Impella CP placement from left femoral artery
7. Impella RP placement from the right femoral vein
8. Intravascular ultrasound of left main and entire LAD
9. Intravascular ultrasound of the right and left external iliac arteries
Recommendations:
Continue heparin drip to maintain ACT more than 250
Advanced heart failure team consult
Continue to monitor hemodynamics
Obtain echocardiogram
Obtain CT scan of the brain chest abdomen and pelvis to rule out aneurysms of the brain, aortic or renal artery aneurysms and dissections
Continue aspirin
Above is the physicians op report. He has indicated to code 93460-26, 92978-26-LD, 75726-26-59, 93503-26, 33990 (impella CP) and 33990 (impella RP). Do I need any modifiers for the two 33990?
Thank you!
Pre-Operative Diagnosis: STEMI
STEMI (7 days)
Typical Angina CCS 4
None
Post Operative Diagnosis:
1. Spontaneous coronary artery dissection of distal LAD with 100% occlusion
2. Spontaneous coronary dissection with intramural hematoma in left main and LAD
3. Cardiogenic shock
4. Angiography of the right external iliac artery is highly suggestive of fibromuscular dysplasia.
5. Swan Gantz catheter placement at the right IJ
6. Impella CP placement from left femoral artery
7. Impella RP placement from the right femoral vein
8. Intravascular ultrasound of left main and entire LAD
9. Intravascular ultrasound of the right and left external iliac arteries
Procedure Performed: DIAGNOSTIC LEFT HEART CATH POSS PCI
-Right heart catheterization
-Leave in Swan placement
-Impella CP placement from left femoral artery
-Impella RP placement from the right femoral vein
-Intravascular ultrasound of left main and entire LAD
- Intravascular ultrasound of the right and left external iliac arteries
Date of Procedure: 11/11/2020
Type of Anesthesia Used: Moderate Sedation
Access site:
Artery: right radial artery right femoral artery, left femoral artery
Vein: right internal jugular vein, right femoral vein
Catheters:
6F IKari 3.5
Description of Findings:
Right dominant system
LM: Mid left main has 60 to 70% stenosis likely due to intramural hematoma.
LAD: Proximal and mid LAD appears normal but tortuous.
-Diagonal 1 is normal
-Distal LAD has an acute band and it is occluded 100% due to spontaneous coronary artery dissection (SCAD)
LCX: Normal, OM1 normal
RCA: Normal
Grafts:
LV-gram: Not performed
LVEDP: 20 mmHg
Procedure details:
Patient was emergently brought to the cardiac catheterization lab. Right wrist and bilateral groins were prepped and draped in standard sterile fashion. 2% lidocaine was infiltrated into the right wrist. Then right radial artery access was obtained using modified Seldinger technique. Then right coronary angiography was performed using IKari 3.5 guide catheter.
LVEDP was measured with the same catheter. Then left coronary angiography was performed with Ikari 3.5 guide catheter
PCI: Due to patient's severe symptoms of 10 out of 10 chest pain, and anatomy suggestive of spontaneous coronary artery dissection decision was made to attempt to perform PCI of distal LAD.
A prowater coronary guidewire was carefully navigated into the mid LAD however it was not able to go into the distal LAD. Then a second run-through coronary guidewire was carefully navigated and after some difficulty we were able to advance the wire into distal LAD. Then intravascular ultrasound catheter was advanced into distal LAD and images were obtained via pullback method from distal LAD to left main. IVUS images showed large circumferential intramural hematoma in mid left main extending into proximal LAD.
As patient became more and more agitated and hemodynamically unstable, decision was made to access right femoral artery.
2% lidocaine was infiltrated into right femoral area and with the use of ultrasound guidance, right femoral artery access was obtained using modified Seldinger technique.
Femoral angiography showed classic beaded appearance of right external iliac artery highly suggestive of fibromuscular dysplasia. Then intravascular ultrasound was performed of this right femoral and external iliac artery which showed inadequate lumen diameter to accommodate 14 French Impella sheath. Then a IMA guide catheter was advanced and left sided external iliac and femoral angiography was performed. Intravascular ultrasound was then performed on the left sided external iliac and femoral artery.
IVUS measurements were adequate for Impella placement. Then Impella CP was placed without any difficulty.
Then 2% lidocaine was infiltrated into right neck and with the use of ultrasound guidance right IJ was accessed and right heart catheterization was performed. Then Swan-Ganz catheter was left into the pulmonary artery for hemodynamic monitoring.
As patient became more and more agitated and her pain was uncontrollable, anesthesia team was called and patient was electively intubated.
During this time, heart team approach was considered and emergent consult with CT surgery was made. After careful discussion, conservative management was recommended with hemodynamic support.
Then after careful discussion decision was made to perform Impella RP placement.
Then 2% lidocaine was infiltrated into right femoral area and right femoral vein access was obtained using modified Salinger technique. Then a 23 French Impella RP sheath was placed without difficulty. On a second timeout, it was discovered that the RP Impella was expired. So so urgent phone calls were made and the nearest RP Impella was available in Bryan Lincoln Hospital. Device rep for Impella RP decided to bring Impella from Bryan Lincoln Hospital. During this time with The patient hemodynamically stable with left-sided Impella CP.
After the Impella RP became available the previously placed 23 French sheath was exchanged and a new sheath was placed. Then Impella RP was placed with the use of balloontipped Swan catheter guidance. Position of Impella RP was confirmed and hemodynamic support was initiated.
Post both Impella S placement, the run-through coronary guidewire was carefully withdrawn and left main coronary guide was disengaged. The guide was then exchanged with a 5 French pigtail catheter and nonselective root angiography was performed which showed no evidence of left main dissection and TIMI I flow in the distal LAD which was previously 100% occluded.
At the end of the case cardiac output was 2.9 L/min on Impella CP and Impella RP.
Throughout the case ACT of more than 250 was maintained with the heparin.
We will start the patient on IV heparin drip.
Closure device: TR Band placement at right radial artery access site.
-Leave in Swan placement right IJ
-Leave in Impella CPin the left femoral artery
-Leave in Impella RP in the right femoral vein
Estimated Blood Loss: Minimal
Specimen(s) Removed: None
Contrast: 245 ml
Radiation dose: 667 mGy
Complications: Transcutaneous bi-ventricular hemodynamic support was placed
Summary:
1. Spontaneous coronary artery dissection of distal LAD with 100% occlusion
2. Spontaneous coronary dissection with intramural hematoma in left main and LAD
3. Cardiogenic shock
4. Angiography of the right external iliac artery is highly suggestive of fibromuscular dysplasia.
5. Swan Gantz catheter placement at the right IJ
6. Impella CP placement from left femoral artery
7. Impella RP placement from the right femoral vein
8. Intravascular ultrasound of left main and entire LAD
9. Intravascular ultrasound of the right and left external iliac arteries
Recommendations:
Continue heparin drip to maintain ACT more than 250
Advanced heart failure team consult
Continue to monitor hemodynamics
Obtain echocardiogram
Obtain CT scan of the brain chest abdomen and pelvis to rule out aneurysms of the brain, aortic or renal artery aneurysms and dissections
Continue aspirin
Above is the physicians op report. He has indicated to code 93460-26, 92978-26-LD, 75726-26-59, 93503-26, 33990 (impella CP) and 33990 (impella RP). Do I need any modifiers for the two 33990?
Thank you!