Left Subclavian Artery Angiography & LIMA Graft Angiography


Saint Joseph, MI
Best answers
Any advice on how to code this procedure would be greatly appreciated. I cannot decide on the cath codes and angiography codes. 36215, 75710, 75756?

Procedures: Selective left subclavian artery angiography, attempted to open the totally occluded left subclavian artery, selective angiography of the left internal mammary artery graft

Date of procedure: 5/6/21

Indication: Totally occluded left subclavian artery, patient is also getting worked for TAVR, ischemia in anterior wall

Procedure performed:
1. Ultrasound of the right common femoral artery and placement of 6 French sheath in the right common femoral artery
2. Attempt to pass the needle in the right radial artery with the help of ultrasound proceed got into the vein
3. Puncture of right renal artery unable to pass the wire through the radial artery
4. Placement of the sheath in right brachial artery
5. Left subclavian artery angiography
6. Attempt to cross the total occlusion of the left subclavian artery both antegradely and retrogradely complex lesion attempt for more than an hour unsuccessful
8. Selective angiography of the left internal mammary artery graft the LIMA diagnostic catheter

Procedure note:
Patient was given total of 4000 units of intravenous heparin and try to maintain ACT of 260. Initially the wire went into the vein into the left arm wire went through all the way distal 014 wire and I was happy to see that probably cross the subclavian artery suffice to say that was the wrong presumption patient's wire went all the way to the right ventricle. And that was realized with the sheath on call patient complains of pain around the 5 French sheath and no return noted after that the sheath and wire and everything was taken out and pressure was applied. Then with the help of ultrasound I was able to puncture the radial artery and wire would not cross through all the way to the forearm. Multiple trans-was done and it was abandoned. Meanwhile already placed 6 French sheath in the right femoral artery. JB 2 diagnostic catheter was passed for antegrade picture, and after the 5 French sheath was placed in the right brachial artery pictures subclavian artery was taken. Subclavian artery was totally occluded however we did see the vertebral artery as well as the LIMA which is filling up adequately I'm sure this is filling up retrogradely in the normal circumstances.
Angiography report to be dictated further down.
The total occlusion was tried to cross with multiple different wires from 0.035 J-tipped 0.035 straight Glide catheter, 0.018 starter wire, 0.014 wire but nothing would cross. Did try to use the Magic cross catheter and it would not go into the intraluminal. My concern was that if I try to dissect too high admit, dissect into the vertebral artery as well as LIMA so we decided after trying for more than our to stop it.
We did do the selective cannulation of the left internal mammary artery to evaluate which was not available possibly related to coronary angiography. Ago.

Cine interpretation:
1. Left subclavian artery is totally occluded
2. Vertebral artery is patent to block the stenosis is below the vertebral artery
3. Left internal mammary artery graft is patent which is filling of the LAD antegradely with no stenosis in the graft or native LAD after the attachment of the graft

Final diagnosis:
1. Totally occluded left subclavian artery at the origin
2. Patent left internal mammary artery graft to the LAD

Options this patient to have Left carotid to subclavian bypass.