LHC - Innominate artery angio and R SCA angio


Port Charlotte, Florida
Best answers
Looking for some guidance with regard to the below procedure. I'm leaning towards CPT code 36225 and CPT code 93458. Any help would be greatly appreciated. Thanks :)

Arterial access was obtained with ultrasound guidance, and modified Seldinger technique to the right radial artery, and a glide 6 French sheath was introduced.
Verapamil 2.5 mg and heparin 4000 units was given intra-arterially upon sheath insertion.
Second arterial access was obtained with the modified Seldinger technique and micropuncture kit to the right common femoral artery.
Once we tried to advance the wire to the subclavian artery, there was evidence of vascular disease, respectively 5 French Jacky catheter was advanced over the wire and placed to the proximal right subclavian artery, and angiogram obtained in RAO caudal projection.
Once we completed the coronary angiogram, we used 5 French JR4 catheter, and placed it to the mid distal innominate artery, and completed innominate artery angiogram in LAO and RAO caudal projection.
5 French JR4 catheter was used for left heart catheterization, and was introduced through the aortic valve to the LV cavity, left ventriculogram was obtained in RAO projection with manual injection of 10 cc of contrast, pullback was performed.
5 French JL4 and JR4 catheters were used for selective coronary angiogram with standard technique.
Blood loss was negligible.
Blood sample was taken for ACT.
Local anesthesia was with 2% lidocaine 2 cc to the right wrist, and 10 cc to the right groin.
Moderate sedation was provided during this procedure with IV Versed 2 mg, IV fentanyl 75 mcg, administered by Cath Lab RN in my presence and under my direct supervision.
Blood pressure, EKG, O2 saturation was continuously monitored.
Sedation time was 25 minutes, there were no immediate complications.
Contrast used–40 cc.
Wrist band was successfully deployed to the right wrist upon completion of the procedure.
Manual management of femoral access site was provided.
Fluoroscopy time was 4 minutes

Aortic pressure was 140/70 mmHg.
Left ventricular pressure was 140/2/7 mmHg, LVEDP was 7 mmHg.
There was no LV to aorta gradient.
Right subclavian artery pressure was 90/60 mmHg, there was 50 mmHg gradient across the ostial proximal right subclavian artery.

Left ventricle appears of mildly dilated with overall preserved systolic function, EF 60%.

Left dominant circulation:
Left main is a large size short vessel without stenosis.
LAD is a medium size moderately to severely calcified vessel, 20% stenosis in the proximal portion, diffuse irregularities in the mid distal portion, but not more than 30% stenosis, vessel gives 2 small diagonal branches.
Circumflex is a large dominant vessel, there is 50% stenosis at the distal segment of the proximal portion, immediately proximal to bifurcation with medium size OM1, OM1 has no significant disease, the mid-– distal circumflex has moderate luminal irregularities but no significant stenosis, it gives medium size OM 2, small to medium size LPL, and medium size L PDA, branches have no obstructive stenosis.
RCA is a small size nondominant vessel, which essentially continues into medium size RV branch and has no significant stenosis.

Considering intraprocedural findings, angiogram was obtained.
Innominate artery is a large calcified vessel originated from type II aortic arch, and by itself has no evidence of significant stenosis it gives rise to the right common carotid artery, which is also large calcified vessel, but has no evidence of significant stenosis.
Right subclavian artery is a large calcified vessel there is 90% proximal portion stenosis, with somewhat decreased flow beyond, and reversed flow from the patent right vertebral artery. The mid and distal portion of the right subclavian artery has no evidence of significant stenosis, right internal mammary artery is patent, right thyrocervical trunk is patent.

1. Nonobstructive coronary artery disease with diffuse calcification of the coronary vessel, 50% stenosis of the dominant proximal circumflex, 20% and 30% stenosis of the LAD.
2. Normal LV systolic function EF 60%.
3. Normal LVEDP 7 mmHg, no LV to aortic gradient.
4. Significant peripheral vascular disease, 90% stenosis with subclavian steal of the right subclavian artery.
5. I recommend and we will plan staged elective angioplasty of the right subclavian artery, which will be performed with dual arterial access, right femoral access with a 5 French sheath and 5 French JR4 catheter for angiogram and good visualization of the artery, and right radial access for the angioplasty, we will plan 8 x 19, or 8 x 29 mm Omnilink stent, respectively will need availability of the 6 French 55 for 65 cm sheath.
6. Meantime patient will have upgrade of his anticholesterol therapy, will increase his rosuvastatin dosage to 20 mg daily, and will add Zetia 10 mg daily, also more aggressive blood pressure management may be needed, however it would be most probably done after revascularization of the right subclavian artery.
I agree with the 93458, but I would code 36140 and 75710-RT for the right subclavian angio. 36225 is for angio. of the vertebral artery and is not documented.