bhargavi
Guru
CLINICAL INDICATIONS
Retrograde right sided aortoiliac dissection.
CLINICAL HISTORY
Mr. is a 65 years old man with known coronary disease and multiple prior
percutaneous interventions. He presented to his primary cardiologist Dr.
office with complaints of exertional chest discomfort. Based on a
high suspicion of coronary disease, he underwent cardiac catheterization
earlier today which revealed severe disease of an osteal ramus intermedius
branch which was not amenable to percutaneous intervention, and moderate in
stent restenosis in the left anterior descending and left circumflex arteries.
In the process of catheter exchange from a standard FR4 diagnostic catheter to
a pigtail catheter, there was significant resistance to wire advancement in the
ileofemoral system. Because of this, the patient's short arterial sheath was
switched for a six French long arterial sheath and nonselective injections
through the sheath revealed what appeared to be a linear retrograde dissection
extending from the bifurcation of the external and internal iliac vessel on the
right, back up to the distal abdominal aorta. There was no evidence of
extravasation and pressure appeared to be grossly intact. However, I was asked
to evaluate the patient for any evidence of significant vascular compromise.
After reviewing the catheterization films, I withdrew the long arterial sheath
down to the level of the mid external iliac vessel. I then obtained a standard
180 centimeters procedural J-wire with the intention of trying to advance this
back into the true lumen of the vessel. Unfortunately, the wire continued to
deflect into the false lumen and I aborted any further attempts at wire
advancement in this area. We did transducer pressure in the external iliac
artery on the right and pressure appeared to be consistent with systemic or
aortic pressure indicating likely no significant vascular compromise. However,
in order to confirm this I elected to obtain left sided arterial access.
TECHNIQUE
We then obtained six French arterial access with a long arterial sheath on the
left side under direct fluoroscopic visualization. We then obtained a six
French angle pigtail catheter which was utilized first for left
ventriculography. Left ventriculography performed in an approximately 20
degrees RAO projection revealed normal left ventricular cavity size, wall
motion and systolic function with an estimated ejection fraction of 55 percent
and no mitral regurgitation.
We then withdrew the pigtail catheter to the level of the distal abdominal
aorta and performed nonselective digital subtraction angiography of the distal
abdominal aorta with bilateral ileofemoral run off. This revealed wide patency
of the distal abdominal aorta and bilateral common external and internal iliac
vessels with no evidence of extravasation, indicating no expansion of
dissection or extravasation of contrast to suggest rupture. We performed a
second digital subtraction angiogram in an LAO view with caudal angulation in
order to evaluate the bifurcation of the external and internal iliac vessels
and this also revealed the area to be widely patent without evidence of any
extraluminal compression or loss of filling. We, therefore, surmised that the
retrograde dissection was of no clinical or hemodynamic significance and would
likely heal with time without any significant intervention.
We then withdrew the long arterial sheath to the level of the mid external
iliac vessel on the left and performed nonselective injection of the left
ileofemoral system which revealed acceptable positioning of the arterial sheath
in the distal left common femoral artery above the common femoral bifurcation.
There was no angiographic evidence of disease at the site of sheath insertion
and as such, a six French MYNX device was deployed for hemostasis after the
long arterial sheath was exchanged for a six French short sheath. This was
successful. We then removed the long arterial sheath from the right common
femoral vessel utilizing manual compression for hemostasis. The patient was
then transferred to the recovery area in stable condition.
IMPRESSION
1. Retrograde non flow limiting dissection extending from external/internal
iliac bifurcation to distal abdominal aorta, not hemodynamically significant
and with no evidence of extravasation or enlargement by contralateral
aortography.
2. Status post MYNX placement on the left.
3. Status post manual compression for hemostasis on the right.
PLAN
Overnight observation to evaluate for any changes.
thanks in advance
my question is cath was done earlier by different doctor. but for this procedure can I bill nonselective abdominal aortograpy 75625-xp or just 93458 by different doctor only
Retrograde right sided aortoiliac dissection.
CLINICAL HISTORY
Mr. is a 65 years old man with known coronary disease and multiple prior
percutaneous interventions. He presented to his primary cardiologist Dr.
office with complaints of exertional chest discomfort. Based on a
high suspicion of coronary disease, he underwent cardiac catheterization
earlier today which revealed severe disease of an osteal ramus intermedius
branch which was not amenable to percutaneous intervention, and moderate in
stent restenosis in the left anterior descending and left circumflex arteries.
In the process of catheter exchange from a standard FR4 diagnostic catheter to
a pigtail catheter, there was significant resistance to wire advancement in the
ileofemoral system. Because of this, the patient's short arterial sheath was
switched for a six French long arterial sheath and nonselective injections
through the sheath revealed what appeared to be a linear retrograde dissection
extending from the bifurcation of the external and internal iliac vessel on the
right, back up to the distal abdominal aorta. There was no evidence of
extravasation and pressure appeared to be grossly intact. However, I was asked
to evaluate the patient for any evidence of significant vascular compromise.
After reviewing the catheterization films, I withdrew the long arterial sheath
down to the level of the mid external iliac vessel. I then obtained a standard
180 centimeters procedural J-wire with the intention of trying to advance this
back into the true lumen of the vessel. Unfortunately, the wire continued to
deflect into the false lumen and I aborted any further attempts at wire
advancement in this area. We did transducer pressure in the external iliac
artery on the right and pressure appeared to be consistent with systemic or
aortic pressure indicating likely no significant vascular compromise. However,
in order to confirm this I elected to obtain left sided arterial access.
TECHNIQUE
We then obtained six French arterial access with a long arterial sheath on the
left side under direct fluoroscopic visualization. We then obtained a six
French angle pigtail catheter which was utilized first for left
ventriculography. Left ventriculography performed in an approximately 20
degrees RAO projection revealed normal left ventricular cavity size, wall
motion and systolic function with an estimated ejection fraction of 55 percent
and no mitral regurgitation.
We then withdrew the pigtail catheter to the level of the distal abdominal
aorta and performed nonselective digital subtraction angiography of the distal
abdominal aorta with bilateral ileofemoral run off. This revealed wide patency
of the distal abdominal aorta and bilateral common external and internal iliac
vessels with no evidence of extravasation, indicating no expansion of
dissection or extravasation of contrast to suggest rupture. We performed a
second digital subtraction angiogram in an LAO view with caudal angulation in
order to evaluate the bifurcation of the external and internal iliac vessels
and this also revealed the area to be widely patent without evidence of any
extraluminal compression or loss of filling. We, therefore, surmised that the
retrograde dissection was of no clinical or hemodynamic significance and would
likely heal with time without any significant intervention.
We then withdrew the long arterial sheath to the level of the mid external
iliac vessel on the left and performed nonselective injection of the left
ileofemoral system which revealed acceptable positioning of the arterial sheath
in the distal left common femoral artery above the common femoral bifurcation.
There was no angiographic evidence of disease at the site of sheath insertion
and as such, a six French MYNX device was deployed for hemostasis after the
long arterial sheath was exchanged for a six French short sheath. This was
successful. We then removed the long arterial sheath from the right common
femoral vessel utilizing manual compression for hemostasis. The patient was
then transferred to the recovery area in stable condition.
IMPRESSION
1. Retrograde non flow limiting dissection extending from external/internal
iliac bifurcation to distal abdominal aorta, not hemodynamically significant
and with no evidence of extravasation or enlargement by contralateral
aortography.
2. Status post MYNX placement on the left.
3. Status post manual compression for hemostasis on the right.
PLAN
Overnight observation to evaluate for any changes.
thanks in advance
my question is cath was done earlier by different doctor. but for this procedure can I bill nonselective abdominal aortograpy 75625-xp or just 93458 by different doctor only