bennieyoung
Guru
I am in discussions with my auditor and she & I disagree on the diagnosis codes for this. Can anyone else give me their opinion? I used I25.700
INDICATION FOR PROCEDURE: NSTEMI.
PROCEDURE:
1. Nonselective right groin sheathogram.
2. Bilateral coronary angiography.
3. Left heart catheterization.
4. Left ventriculogram.
5. Right internal mammary artery angiography to RCA.
6. Left internal mammary artery angiography to the LAD.
HISTORY: Briefly, this is an 85-year-old male with history of CABG, who presents with complaints of chest pain. The patient was found to have elevated troponin levels and was consented for catheterization.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to catheterization where the right groin was prepped in sterile fashion. Using local lidocaine, a short 6-French sheath was placed into this right common femoral artery. Given the tortuosity of the iliac system, the patient was upsized to a 6-French 45 cm sheath. After a stiff wire was placed, a JL4 catheter was then placed to the left coronary artery. Images of the left coronary artery revealed normal left main. Left circumflex artery was 100% occluded after its ostial takeoff. There was a large diagonal 1 takeoff which was healthy and free of disease. There was a 2nd smaller diagonal artery, which was healthy and free of disease. Medially after this, the LAD appeared to be 100% occluded. After these images were obtained, the JL4 catheter was removed. The JR4 catheter was advanced to the right coronary artery. Images of the right coronary artery revealed 100% occluded proximal RCA. The JR4 catheter was then pulled back and placed into the 1st graft, which apparently was 100% occluded graft which most likely was feeding the marginal system and this was known to be occluded apparently by the patient on his prior angiograms. We then switched out for an angled glide catheter and Glidewire and subselective angiography of the right internal mammary artery was obtained which showed widely patent LIMA graft anastomosing into the distal RCA. The RPDA appeared to be widely patent proximally as is the RPLS; however, it appeared in the extreme distal aspect of the RPDA, there was what appeared to be thrombus. This catheter could not get selective. Thus, we switched this out for an IMC catheter. Angiography of the IMC revealed widely patent RIMA graft anastomosing to the distal RCA. Once again, re-demonstrating that there appeared to be at the most extreme distal aspect of the vessel occluded flow, but again this was potentially a 0.1 to 0.2 size vessel distally, which had this area of limited flow. At this time too, it was noted that after this happened, the patient did have ST elevations, but was chest pain free. The catheter was removed and switched out for a JR4 catheter and the left internal mammary artery was then subsequently cannulated and this showed a widely patent anastomosis, while in the distal LAD had mild plaque disease, but no significant obstruction. Of note, there was collateralization that appeared to be to the circumflex system as well coming off the distal LAD. After these images were obtained, the LIMA catheter was removed and a pigtail catheter was advanced in the left ventricle. EDP was 12 mmHg. Left ventriculogram in the RAO projection showed EF of 65% with no wall motion abnormalities. No pullback gradient between the LV and the aorta. Pigtail catheter removed over the 0.035 wire. Right groin was closed with 6-French Angio-Seal. Patient tolerated the procedure well with no complications.
IMPRESSION:
1. Widely patent LIMA graft and RIMA graft.
2. Occluded presumable saphenous vein graft to marginal artery.
3. Normal ejection fraction.
4. Severe native left coronary artery disease.
5. Severe native right coronary artery disease.
6. Evidence of extreme distal thrombus in the right coronary artery, potentially embolic in nature, which most likely explains the patient's presentation, which is not amenable to PCI as it is in the extreme distal aspect of the vessel and it measures only approximately 0.25.
PLAN: The patient will be on aggressive medical therapy. He received double bolus of Integrilin during the case. Will be placed on a heparin drip for 24 hours in a few hours. He will remain on aspirin, Plavix and statin. Currently, the patient is chest pain free. Further orders following clinical course.
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INDICATION FOR PROCEDURE: NSTEMI.
PROCEDURE:
1. Nonselective right groin sheathogram.
2. Bilateral coronary angiography.
3. Left heart catheterization.
4. Left ventriculogram.
5. Right internal mammary artery angiography to RCA.
6. Left internal mammary artery angiography to the LAD.
HISTORY: Briefly, this is an 85-year-old male with history of CABG, who presents with complaints of chest pain. The patient was found to have elevated troponin levels and was consented for catheterization.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to catheterization where the right groin was prepped in sterile fashion. Using local lidocaine, a short 6-French sheath was placed into this right common femoral artery. Given the tortuosity of the iliac system, the patient was upsized to a 6-French 45 cm sheath. After a stiff wire was placed, a JL4 catheter was then placed to the left coronary artery. Images of the left coronary artery revealed normal left main. Left circumflex artery was 100% occluded after its ostial takeoff. There was a large diagonal 1 takeoff which was healthy and free of disease. There was a 2nd smaller diagonal artery, which was healthy and free of disease. Medially after this, the LAD appeared to be 100% occluded. After these images were obtained, the JL4 catheter was removed. The JR4 catheter was advanced to the right coronary artery. Images of the right coronary artery revealed 100% occluded proximal RCA. The JR4 catheter was then pulled back and placed into the 1st graft, which apparently was 100% occluded graft which most likely was feeding the marginal system and this was known to be occluded apparently by the patient on his prior angiograms. We then switched out for an angled glide catheter and Glidewire and subselective angiography of the right internal mammary artery was obtained which showed widely patent LIMA graft anastomosing into the distal RCA. The RPDA appeared to be widely patent proximally as is the RPLS; however, it appeared in the extreme distal aspect of the RPDA, there was what appeared to be thrombus. This catheter could not get selective. Thus, we switched this out for an IMC catheter. Angiography of the IMC revealed widely patent RIMA graft anastomosing to the distal RCA. Once again, re-demonstrating that there appeared to be at the most extreme distal aspect of the vessel occluded flow, but again this was potentially a 0.1 to 0.2 size vessel distally, which had this area of limited flow. At this time too, it was noted that after this happened, the patient did have ST elevations, but was chest pain free. The catheter was removed and switched out for a JR4 catheter and the left internal mammary artery was then subsequently cannulated and this showed a widely patent anastomosis, while in the distal LAD had mild plaque disease, but no significant obstruction. Of note, there was collateralization that appeared to be to the circumflex system as well coming off the distal LAD. After these images were obtained, the LIMA catheter was removed and a pigtail catheter was advanced in the left ventricle. EDP was 12 mmHg. Left ventriculogram in the RAO projection showed EF of 65% with no wall motion abnormalities. No pullback gradient between the LV and the aorta. Pigtail catheter removed over the 0.035 wire. Right groin was closed with 6-French Angio-Seal. Patient tolerated the procedure well with no complications.
IMPRESSION:
1. Widely patent LIMA graft and RIMA graft.
2. Occluded presumable saphenous vein graft to marginal artery.
3. Normal ejection fraction.
4. Severe native left coronary artery disease.
5. Severe native right coronary artery disease.
6. Evidence of extreme distal thrombus in the right coronary artery, potentially embolic in nature, which most likely explains the patient's presentation, which is not amenable to PCI as it is in the extreme distal aspect of the vessel and it measures only approximately 0.25.
PLAN: The patient will be on aggressive medical therapy. He received double bolus of Integrilin during the case. Will be placed on a heparin drip for 24 hours in a few hours. He will remain on aspirin, Plavix and statin. Currently, the patient is chest pain free. Further orders following clinical course.
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