Ivus
INDICATIONS: Angina pectoris.
PROCEDURE: Left heart catheterization, coronary angiography, left ventriculography with attempted intravascular ultrasound.
HISTORY OF PRESENT ILLNESS: The patient with severe coronary artery disease with previous percutaneous interventions to his left AV groove and left PDA with Xience stents in October of 2011, as well as LAD stenting previously in 2010.
He presented with progressive accelerating anginal symptoms despite aggressive up titration of medical therapy. He had felt better after his previous PCI; however, over the last few months had progressive symptoms. He underwent angiography.
PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives procedure and agreed to proceed with the procedure. The right wrist was prepped in the usual sterile fashion and 2% lidocaine infused subcutaneously
until adequate anesthesia was obtained. Right radial artery accessed using modified Seldinger technique. A 6 French 250 mm Glidesheath was placed without complication. Diagnostic 6 French Jacky catheter was used to perform selective coronary
angiography, left ventriculography, and left heart catheterization. At the conclusion of the procedure, a TR band was used for hemostasis.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 12 mmHg. There was no transaortic gradient on pullback.
LEFT VENTRICULOGRAPHY: Demonstrated preserved left ventricular function, ejection fraction of 55%.
CORONARY ANGIOGRAPHY
LEFT MAIN: There was difficult engagement at the left main coronary artery. There was significant calcium. No catheter dampening however was observed. Upon the use of an EBU 3.75 guide catheter there appeared to be a 70% ostial stenosis with a large
rim of calcium.
LAD: Moderate disease. There is a stent seen in the midvessel portion of about 40-50% restenosis. There was a first diagonal that had mild diffuse disease.
LEFT CIRCUMFLEX: A large, dominant circulation. There is patent stent seen in the second marginal and left PDA as well as in the proximal vessel. There was a prominent first marginal that was totally occluded being fed by left-to-left collaterals.
RCA: Nondominant and diminutive.
SUMMARY: Critical multivessel coronary artery disease with high-grade ostial left main and chronic totally occluded first marginal. Of note, due to difficulty of selective engagement intravascular ultrasound was attempted.
INTERVENTION: Angiomax was used for effective anticoagulation. An EBU 3.5 guide catheter was used to intubate the left main. The wire was navigated with much difficulty to the distal LAD. However, due to excessive calcium and high-grade stenosis seen
in the ostium of the left main the IVUS catheter was not able to be traversed across the left main. The procedure was abandoned.
SUMMARY: Critical left main and high-grade first marginal disease best optimally treated with surgical revascularization.
CLINICAL PATHWAY: The patient will be referred for coronary artery bypass grafting. We hope this will afford him symptomatic relief as well as improvement of long-term mortality.
Sorry this took so long, very busy here Thanks for anything you can tell me Medicare keeps denying the 92978 stating either modifier missing or modifier incorrect