Question kissing angioplasty

AgnieszkaMarek

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I am perplexed how to code the kissing angioplasty procedure. I code for facility and I will be using C9600 code instead 92928. how can I capture this procedure? I would code;
93458-59
C9600-LD
92978-LD
93571-RC
question is; do I even code the kissing angioplasty or not, if so how 92920,92921? if I code this way I may get edit that 92920-LD is included in PCI stent placement



PREOPERATIVE DIAGNOSIS:
Unstable angina
POSTOPERATIVE DIAGNOSIS:
Unstable angina
One-vessel CAD-de novo critical distal edge re-stenosis at first diagonal
Patent LAD diagonal bifurcation stents
Nonobstructive stenosis of the proximal RCA
PROCEDURE:
Left heart catheterization
Coronary angiography (93458)
PCI of first diagonal with a drug-eluting stent (92928-LD)
Balloon angioplasty of mid LAD (92921-LD)
IVUS of the LAD (92978)
Resting pressure gradient (DFR)of the RCA (93571)
FINDINGS:
Coronary angiography:
Right dominance.

Left main-short, mild diffuse disease. Gives rise to the LAD and LCx.

LAD-large, wraparound with mild diffuse disease. Stents at proximal and mid segments are patent. Bifurcation stent at the origin of the large first diagonal is patent with critical 90% distal edge restenosis with TIMI-3 flow.

LCx-moderate size, mild diffuse disease, mainly gives a large inferior marginal. High first marginal is small and patent. The inferior marginal is large and patent.

RCA-dominant, large vessel. There is heavy calcification at the ostium with mild 20 to 30% stenosis and additional focal up to 50% stenosis at proximal portion few millimeter from the ostium. Rest of the vessel is widely patent with large PDA and RPL system.

Left ventricle: LV angiography not performed, EDP-8 mmHg, no aortic stenosis.

IVUS of the LAD into the first diagonal: The diagonal vessel is very large with reference vessel diameter of 4.0 mm at the ostium tapering to 3.5 mm at midportion. The pre-existing stent is undersized in reference to the vessel diameter (2.75 mm caliber stent).

Intervention: Successful balloon angioplasty and IVUS guided stenting of first diagonal with a DES Synergy 3.0/12 mm stent-overlapping with the distal edge of the pre-existing stent. High-pressure postdilatation with a 3.5 mm NC balloon. Kissing balloon inflation at LAD diagonal bifurcation with a 3.5 mm NC balloon at the diagonal and 3.0 mm balloon at mid LAD. Excellent final angiographic result with 0% residual stenosis at the diagonal and final TIMI-3 flow.

Hemodynamic assessment of the RCA: Resting pressure gradient indicates nonobstructive disease with a DFR of 0.95 (abnormal is less than 0.90).

Conclusions:
1. Indication-recent onset worsening dyspnea on exertion suspicious to be angina equivalent. 78-year-old male, history of anterior wall MI 30 years ago and complex PCI of LAD diagonal bifurcation in 2014 at NYU. Recent NST in last September showed small apical scar without ischemia. Patient presented with new symptoms of dyspnea on exertion similar to prior symptoms before LAD stenting. Referred for left heart catheterization.
2. Patent stents in LAD diagonal bifurcation with de novo critical distal edge restenosis in the large first diagonal.
3. Nonflow limiting disease of the RCA based on resting pressure gradient (DFR).
4. Successful IVUS guided stenting of the first diagonal with a drug-eluting stent. Kissing balloon inflation at LAD diagonal bifurcation.

DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was brought to the cardiac catheterization lab prepped and draped in usual sterile manner for right radial procedure. An Allen's test performed preprocedure was physiologically normal. The patient was sedated with Versed and fentanyl. 2% lidocaine applied to the right radial area and a 6 French sheath was placed. Selective left coronary angiography was performed with a 5F TIG 4 catheter. LV catheterization was performed with an AR2 catheter, which was then pulled back and used for selective right coronary angiography.

We then proceeded with intervention on the critical lesion in the first diagonal. Angiomax bolus was given and drip started. Patient was given 180 mg of Brilinta. An EBU 3.5 6F guiding catheter was used to engage the left main. A run-through wire was advanced into the diagonal branch. The lesion was pre-dilated witha 2.5/12 mm NC balloon. We performed IVUS of the diagonal branch with an Opticross catheter. Analysis of the IVUS images was performed. We attempted to deliver a stent into the diagonal, but the stent could not to be advanced into the diagonal. Therefore, we performed kissing balloons at the LAD diagonal bifurcation with a 3.5 mm NC balloon in the diagonal branch and a 3.0 mm NC balloon in the mid LAD . After that, we were able to successfully deliver the stent. A DES Synergy 3.0/12 mm stent was deployed in the midportion of the diagonal branch overlapping with the distal edge of the pre-existing stent. The stent was further postdilated with a 3.5 mm NC balloon. We used the same balloon to further dilate the pre-existing more proximal diagonal stent.
Completion angiography showed very good angiographic result with 0% residual stenosis and final TIMI 3 flow.

We then addressed the borderline lesion in the proximal RCA with a resting pressure gradient. The RCA was engaged with an AR-2 6F guiding catheter. A Comet pressure wire was advanced to the distal RCA and DFR was measured showing a non flow-limiting lesion.
 
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