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LHC, angiography, bypass graft angiography and PCI


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Please help me code this from the following report I received a denial for using the RI modifier but I may have needed a modifier 59 on the LHC:

PROCEDURE: Left heart catheterization, coronary angiography, bypass graft
angiography, percutaneous intervention of saphenous vein graft to ramus.

PROCEDURE IN DETAIL: After informed consent was obtained, the patient was
brought to the lab and placed on the table. He was prepped and draped in the
usual sterile manner. Access was obtained in the right common femoral artery
using a 6-French sheath using a micropuncture kit and modified Seldinger
technique. Due to excessive tortuousity of the aorta and iliac arteries, a 6 Fr
Destination sheath 45 cm was placed through the right common femoral artery.
Diagnostic coronary angiography was performed with a 6-French Tiger catheter, a
6-French JR4 catheter, a 6-French multipurpose catheter and a 6-French pigtail
catheter. The left heart cath was performed by passing the wire retrograde
through the aortic valve into the left ventricle and a 6-French JR4 catheter
was advanced into the LV and hemodynamics were measured and the catheter was
pulled back across the aortic valve. An aortogram was performed by positioning
a 6-French pigtail catheter in the infrarenal aorta using the power injector,
10 mL per second for a total volume of 20 mL, 500 psi and 0 second rise time.
An aortic root shot was also performed using a pigtail catheter and injecting
20 mL per second for a total of 20 mL of contrast.

1. Left main coronary artery is a medium sized vessel with ostial 50% stenosis
and distal 60% stenosis.
2. Left anterior descending coronary artery is a medium size vessel with
proximal 90% diffuse stenosis. The mid LAD has 100% chronic total occlusion.
3. Ramus intermedius has a proximal 100% chronic total occlusion.
4. The circumflex coronary artery has 100% proximal stenosis.
5. The right coronary artery has 100% chronic total occlusion in the mid RCA.
6. The LIMA to LAD is patent with good distal runoff.
7. The saphenous vein graft to the ramus or a large first diag has a 99%
stenosis in the midportion and a 90% proximal discrete stenosis.
8. The saphenous vein graft to the RPDA has 100% proximal stenosis.
9. The saphenous vein graft to the RPLB is occluded at the aortic anastomosis

Aortogram was performed, showed a tortuous calcified aorta and tortuous iliac
vessels. There was mild atheroma seen in the infrarenal aorta. The renal
artery was patent bilaterally. The common iliac was tortuous, but patent. The
external iliac was tortuous, but patent. The internal iliac is patent.

Aortogram, a root shot was performed, to visualize any patent grafts. It showed
the saphenous vein graft to the RPDA with 100% proximal stenosis and the
saphenous vein graft to the ramus.

HEMODYNAMICS: Left heart cath, the LV pressure was 118/-6, LVEDP was 16, the AO
pressure was 114/68. There was no gradient on pullback.

was obtained using Angiomax. Brilinta loading dose of 180 mg p.o. was given.
A JR4 guide catheter was used to engage the saphenous vein graft to the ramus.
A BMW wire was passed across the stenosis in the vein graft. A Spider 4.0
distal embolic protection filter was then advanced across the stenosis and
deployed in the distal one-third of the vein graft to ramus. Dilatation of the
stenosis was obtained with Sprinter RX 3.0 x 15 mm inflated at 12 atmospheres
for 20 seconds. A TREK RX 3.5 x 8 mm balloon was inflated at 12 atmospheres
for a total of 20 seconds at the proximal stenosis. It was attempted to pass
XIENCE 3.5 x 15 mm stent; however, it would not pass across the proximal
stenosis and this was removed. The TREK RX 3.5 x 8 mm balloon was then passed
across the mid stenosis again and inflated at 14 atmospheres for 20 seconds.

Following this, an injection showed the distal embolic protection filter was
filled with debris. The Spider was retrieved and removed. Injection through
the JR4 guide into the vein graft showed the stenosis in the mid vein graft was
reduced to 20%. Cardene 100 mcg was injected into the vein graft which showed
TIMI-2 flow distally. The BMW was used to re-cross into the distal vein graft.
A Sprinter OTW balloon 1.25 x 6 mm balloon was advanced over the BMW. The BMW
was removed and Cardene 100 mcg was injected through the over the wire balloon.
Contrast injection post procedure showed TIMI-3 flow in the distal vein graft
in the distal vessel. The destination sheath was then exchanged for a short
6-French sheath and hemostasis was obtained with a 6-French Angioseal.




1. Continue aspirin for life.
2. Brilinta for at least 1 month.
3. Continue beta blockers and statin.
4. Complete echo.