bhargavi
Guru
Conclusion
78-year-old male presenting with recurrent episodes of chest discomfort. He is known to have coronary artery bypass graft surgery. The stress test showed anterior ischemia. He was referred for cardiac catheterization procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 1:04 PM and monitoring period Ended 3:09 PM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery. Cardiac catheterization was performed using the usual catheters.
Finding:
1: The left main was 100% occluded
2: Right coronary artery: Right coronary artery is 100% occluded proximally. There are bridging collaterals filling the distal vessel
3: There is a vein graft probably going to the right coronary artery that is 100% occluded
4: A vein graft to the obtuse marginal branch has an ostial severe 99% stenosis.
5: Left subclavian angiogram showed 70% left subclavian artery stenosis with a 50 mm gradient. The left internal mammary artery to the left anterior descending artery showed a patent vessel
6: Left heart catheterization with left ventricular angiogram showed mild inferior wall hypokinesis overall estimated ejection fraction 50%.
*
Impression: Occlusion of native vessels and a patent left internal mammary artery to left anterior descending artery with 70% left subclavian stenosis and 99% stenosis in the ostium of the vein graft to the obtuse marginal branch.
*
Plan: Proceed with attempt stenting of the vein graft to the obtuse marginal branch.
*
Intervention:
*
Using a L CB guiding catheter and a ATW marker wire I was able to cross to severe stenosis in the ostium of the vein graft to the obtuse marginal branch. Initial attempt to cross with a distal protection device failed. An ATW marker wire was then used and able to cross. Balloon angioplasty with 3 oh by 15 mm balloon failed as the balloon could not catch on the lesion and kept slipping. The double wire with the BMW was then used. 3.0 x 10 mm cutting thing balloon was used repeatedly followed by a 4.0 balloon. The lesion was reduced to less than 50% stenosis. After that attempt to cross the 5 x 18 mm bare-metal stent failed despite multiple attempts. This was then withdrawn and a 4.0 x 15 mm XIENCE was attempted however it could not cross due to combination of poor guide support and severe stiffness in the body of the lesion itself. A 5 mm balloon was then used to dilate the area. We attempted with a stent also failed. The procedure was aborted. Repeat angiogram performed showed stable flow in the graft.
Final impression:
*
Occlusion of native vessels and a patent left internal mammary artery to left anterior descending artery with 70% left subclavian stenosis and 99% stenosis in the ostium of the vein graft to the obtuse marginal branch. Angioplasty with a 5 mm balloon to the origin of the vein graft to the obtuse marginal branch was performed however stenting failed.
*
Plan:
Medical treatment. The patient continues to have refractory symptoms despite adding Plavix consider redo coronary artery bypass graft surgery
*should I code 93458-xu, 92920?
*
78-year-old male presenting with recurrent episodes of chest discomfort. He is known to have coronary artery bypass graft surgery. The stress test showed anterior ischemia. He was referred for cardiac catheterization procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 1:04 PM and monitoring period Ended 3:09 PM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery. Cardiac catheterization was performed using the usual catheters.
Finding:
1: The left main was 100% occluded
2: Right coronary artery: Right coronary artery is 100% occluded proximally. There are bridging collaterals filling the distal vessel
3: There is a vein graft probably going to the right coronary artery that is 100% occluded
4: A vein graft to the obtuse marginal branch has an ostial severe 99% stenosis.
5: Left subclavian angiogram showed 70% left subclavian artery stenosis with a 50 mm gradient. The left internal mammary artery to the left anterior descending artery showed a patent vessel
6: Left heart catheterization with left ventricular angiogram showed mild inferior wall hypokinesis overall estimated ejection fraction 50%.
*
Impression: Occlusion of native vessels and a patent left internal mammary artery to left anterior descending artery with 70% left subclavian stenosis and 99% stenosis in the ostium of the vein graft to the obtuse marginal branch.
*
Plan: Proceed with attempt stenting of the vein graft to the obtuse marginal branch.
*
Intervention:
*
Using a L CB guiding catheter and a ATW marker wire I was able to cross to severe stenosis in the ostium of the vein graft to the obtuse marginal branch. Initial attempt to cross with a distal protection device failed. An ATW marker wire was then used and able to cross. Balloon angioplasty with 3 oh by 15 mm balloon failed as the balloon could not catch on the lesion and kept slipping. The double wire with the BMW was then used. 3.0 x 10 mm cutting thing balloon was used repeatedly followed by a 4.0 balloon. The lesion was reduced to less than 50% stenosis. After that attempt to cross the 5 x 18 mm bare-metal stent failed despite multiple attempts. This was then withdrawn and a 4.0 x 15 mm XIENCE was attempted however it could not cross due to combination of poor guide support and severe stiffness in the body of the lesion itself. A 5 mm balloon was then used to dilate the area. We attempted with a stent also failed. The procedure was aborted. Repeat angiogram performed showed stable flow in the graft.
Final impression:
*
Occlusion of native vessels and a patent left internal mammary artery to left anterior descending artery with 70% left subclavian stenosis and 99% stenosis in the ostium of the vein graft to the obtuse marginal branch. Angioplasty with a 5 mm balloon to the origin of the vein graft to the obtuse marginal branch was performed however stenting failed.
*
Plan:
Medical treatment. The patient continues to have refractory symptoms despite adding Plavix consider redo coronary artery bypass graft surgery
*should I code 93458-xu, 92920?
*
Last edited: