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INDICATIONS: nstemi
Leftheart cath, selective coronary angiography, emergent percutaneous intervention of the external iliac w/placement of self-expanding stent
PROCEDURE: Right common femoral artery accessed using modified Seldinger technique of which a 6 French 11 cm sheath was placed. Diagnostic angiography was performed w/JL4 & 3DRC catheter as well as a pigtail catheter for LHC and aortography. Manual compression was used for hemostasis.
Hemodynamics: L ventricular end-distolic pressure measured 7 mmHG. There was no transaortiic gradient on pullback.
CORONARY ANGIOGRAPHY:
Left MAin: No significant disease
LAD: Patent stent in its proximal portion; however no significant disease. Diagonal w/o significant disease.
LC: Gave off prominent marginal w/mild disease.
RCA: Dominant vessel w/mild disease w/prominent PL and PDA branches w/o significant obstruction.
SUMMARY:
1 No obstructive coronary disease w/patent stents seen in the LAD
2 Normal left ventricular filling pressures
Upon evaluation in the right femoral artery insertion site, it was determined the patient had no flow extending from the takeoff of the external iliac down, compromising the entire circulation in the lower extremity. It was determined the patient had an external iliac dissection.
INTERVENTION: Contralateral access was achieved using a 6 French sheath and a Contra catheter was then placed in the abdominal aorta. A pigtail catheter was used to perform an abdominal aortogram, which demonstrated significant calcification and disease at the aortoiliac junction. Multiple times using a Glidewire were used with a Contra catheter to cross over to gain purchase into the true lumen of the external iliac. However, due to the extreme calcification and disease at the aortoiliac bifurcation, the Contra catheter would not traverse across the bifurcation. An IMA catheter was then exchanged and used to perform selective iliac angiography in an antigrade fasion, which demonstrated obstructive flow seen at the takeoff of the internal iliac. There was faint reconstitution of the SFA and deep femoral seen distally. As such, we will antegrade injection with the 6 French sheath in the right common fermoral artery also revealed the same issue. A wire was then again attempted to regain access to the true lumen. This was eventually achieved upon gentle pullback of the 5 French sheath into the true lumen, of which then purchase was then achieved using a Glidewire. At this time, the 5 French sheath was then exchanged for 6 French BRITE TIP sheath. This was placed into the external iliac. It was still within the false lumen. At that point in time a 6.0x8.0 LifeStent was then loaded upon an 0.35 wire. The BRITE TIP sheath was then withdrawn until approximately 2.0 mm proximal to the common femoral insertion point. This stent was then selfexpanded within the true lumen as the wire was the redirected and was able to recannulate and establish flow from this intervention, she had nonpalpable pulses. However, at the conclusion of the procedure, she had excellent runoff with 2+ pulses. Manual compression was used for hemostasis of the right common femoral and the sheath was sutured on the left for eventual withdraw within one hour.
Dr wants to bill for
93458-26-59
access to artery 36246-59
second order cath ?
imaging second -order iliac 75710-26-59
RLE right lower extremity ?
stent iliac w/SI 37221
What do we have right and what's wrong Thanks for your input. Nancy
Leftheart cath, selective coronary angiography, emergent percutaneous intervention of the external iliac w/placement of self-expanding stent
PROCEDURE: Right common femoral artery accessed using modified Seldinger technique of which a 6 French 11 cm sheath was placed. Diagnostic angiography was performed w/JL4 & 3DRC catheter as well as a pigtail catheter for LHC and aortography. Manual compression was used for hemostasis.
Hemodynamics: L ventricular end-distolic pressure measured 7 mmHG. There was no transaortiic gradient on pullback.
CORONARY ANGIOGRAPHY:
Left MAin: No significant disease
LAD: Patent stent in its proximal portion; however no significant disease. Diagonal w/o significant disease.
LC: Gave off prominent marginal w/mild disease.
RCA: Dominant vessel w/mild disease w/prominent PL and PDA branches w/o significant obstruction.
SUMMARY:
1 No obstructive coronary disease w/patent stents seen in the LAD
2 Normal left ventricular filling pressures
Upon evaluation in the right femoral artery insertion site, it was determined the patient had no flow extending from the takeoff of the external iliac down, compromising the entire circulation in the lower extremity. It was determined the patient had an external iliac dissection.
INTERVENTION: Contralateral access was achieved using a 6 French sheath and a Contra catheter was then placed in the abdominal aorta. A pigtail catheter was used to perform an abdominal aortogram, which demonstrated significant calcification and disease at the aortoiliac junction. Multiple times using a Glidewire were used with a Contra catheter to cross over to gain purchase into the true lumen of the external iliac. However, due to the extreme calcification and disease at the aortoiliac bifurcation, the Contra catheter would not traverse across the bifurcation. An IMA catheter was then exchanged and used to perform selective iliac angiography in an antigrade fasion, which demonstrated obstructive flow seen at the takeoff of the internal iliac. There was faint reconstitution of the SFA and deep femoral seen distally. As such, we will antegrade injection with the 6 French sheath in the right common fermoral artery also revealed the same issue. A wire was then again attempted to regain access to the true lumen. This was eventually achieved upon gentle pullback of the 5 French sheath into the true lumen, of which then purchase was then achieved using a Glidewire. At this time, the 5 French sheath was then exchanged for 6 French BRITE TIP sheath. This was placed into the external iliac. It was still within the false lumen. At that point in time a 6.0x8.0 LifeStent was then loaded upon an 0.35 wire. The BRITE TIP sheath was then withdrawn until approximately 2.0 mm proximal to the common femoral insertion point. This stent was then selfexpanded within the true lumen as the wire was the redirected and was able to recannulate and establish flow from this intervention, she had nonpalpable pulses. However, at the conclusion of the procedure, she had excellent runoff with 2+ pulses. Manual compression was used for hemostasis of the right common femoral and the sheath was sutured on the left for eventual withdraw within one hour.
Dr wants to bill for
93458-26-59
access to artery 36246-59
second order cath ?
imaging second -order iliac 75710-26-59
RLE right lower extremity ?
stent iliac w/SI 37221
What do we have right and what's wrong Thanks for your input. Nancy