bhargavi
Guru
INDICATIONS
Chest pain.
Acute coronary syndrome.
Acute posterior wall myocardial infarction.
PROCEDURES
Left heart catheterization.
Left ventriculography.
Left internal mammary graft angiography.
Vein graft angiography.
Coronary angiography.
Percutaneous coronary intervention with angioplasty and drug eluting stent
treatment of circumflex disease stenosis and additional drug eluting stent
treatment of severe left main coronary artery stenosis and disease.
DESCRIPTION OF PROCEDURE
The patient was brought to emergently from the Emergency Department and after
consent was obtained, a six French sheath was placed in the right common
femoral artery under fluoroscopic guidance. A six French Judkins diagnostic
left coronary catheter was then utilized for left coronary angiography. The
right coronary angiography was performed with a Judkins right coronary catheter
as well as vein graft angiography and left internal mammary graft angiography.
After identification of the critical culprit lesion at previously stented
osteal or proximal circumflex, there was additional progressive disease culprit
lesion in the mid circumflex, below the stented segment, as well as severe
restenosis in the left main coronary artery separately. An EBU 3.75 guiding
catheter was then advanced into the left main coronary artery and a coronary
wire was advanced into the distal circumflex. Angioplasty was performed with a
Boston Scientific Quantum, noncompliant high pressure balloon, initially a 2.75
by 12 millimeters balloon for the left main stenosis and across the ostium of
the circumflex. Additional opening of this segment was then performed with a
3.0 by 12 millimeters Quantum balloon after the first balloon ruptured.
Indeed, the second balloon ruptured. Thereafter, this segment was felt to be
adequately patent and a Boston Scientific Emerge balloon, 2.25 by 20
millimeters, was then easily passed into the mid circumflex and angioplasty was
performed of the denovo progressive stenosis culprit lesion. This was a 2.25 by
20 millimeters Emerge balloon. Stenting was then performed with initial
placement of a Boston Scientific Promus PREMIER drug eluting stent, 2.25 by 20
millimeters, overlapping with the previous proximal stent, extending into the
mid vessel. This would not quite advance all the way distally. This was
deployed and due to additional disease at the edge, a second 2.25 by 8
millimeters Boston Scientific Promus PREMIER drug eluting stent was deployed
with overlap extending slightly further into the mid circumflex. This entire
segment was then post dilated with the 2.25 millimeters Emerge and subsequently
the 3.0 millimeters Quantum balloon. Thereafter, further angioplasty was
performed of the left main stenosis with a 3.5 Quantum balloon. Thereafter, a
larger Boston Scientific Promus PREMIER drug eluting stent 3.5 by 20
millimeters was deployed for the left main stenosis and this stent was deployed
extending from the ostium of the left main to the bifurcation. There was
overlap with the previously placed stent. This entire segment was then post
dilated with a 3.5 by 12 millimeters Boston Scientific NC Quantum high pressure
balloon to 24 and 26 atmospheres. Finally without balloon rupture and with
excellent angiographic result after intracoronary nitroglycerin and withdrawal
of the balloon and wire. A six French pigtail catheter was then utilized for
left heart catheterization and left ventriculography. Ileofemoral angiography
confirmed the sheath in the common femoral artery and closure was obtained with
an Angio-Seal closure device. There were no complications.
HEMODYNAMICS
The intraaortic pressure was 135/70.
The left ventricular pressure was 135/20 with mildly elevated left ventricular
end diastolic pressure and no transaortic valvular gradient.
No left ventriculography was performed due to the large volume of contrast
necessary for the diagnostic angiography due to the patient's anatomy, grafts
and two vessel angioplasty as detailed above.
ANGIOGRAPHIC FINDINGS
The right coronary artery was known to be chronically occluded. There was no
graft to the distal right coronary artery. Those vessels do fill from distal
branches of the circumflex and possible left anterior descending.
The left main was calcified. There was a stent extending from the ostium of the
circumflex into the proximal circumflex. This stent did demonstrate some
moderate in stent restenosis. Below this stent, there was denovo lesions in
the mid circumflex up to 90 percent with hazy ulcerated plaque appearance. The
left main itself in several projections appeared to be patent but in the
cranial projection, had a subtotal occlusion ulcerated plaque as well. This
was a brand new lesion from the March 2014 angiogram. This was a nondominant
but large distal distribution circumflex which did collateralize the distal
right coronary artery. The left anterior descending despite the stent, in the
left main and the circumflex, remained patent proximally and there was
competitive filling of this mid vessel through a patent mammary graft. The left
internal mammary graft to the mid left anterior descending was widely patent.
The vein graft to the major diagonal was widely patent with a widely patent
stent in the vessel as well. No change was noted angiographically.
Intervention as described above, successful angioplasty and stenting with drug
eluting stenting performed of the mid circumflex new lesion, with overlap of
the previously placed proximal circumflex stent and additionally the left main
coronary angioplasty and large drug eluting stent placement were performed for
the left main stenosis.
SUMMARY AND CONCLUSIONS
1. Chest pain, acute coronary syndrome and acute myocardial infarction with
acute posterior wall infarction.
2. Critical lesions in the mid circumflex and left main coronary artery, each
treated with drug eluting stent placement.
3. Patent mammary graft to the left anterior descending and vein graft to the
major diagonal.
4. Chronically occluded right coronary artery with collaterals.
5. Moderately elevated left ventricular end diastolic pressure.
RECOMMENDATION
Aggressive risk factor modification, aspirin and Clopidogrel duel antiplatelet
therapy.
should i do 93459-xu,c9606,c9601 or 93459-xu, c9606,c9600 i am hospital coder. thanks in advance
Chest pain.
Acute coronary syndrome.
Acute posterior wall myocardial infarction.
PROCEDURES
Left heart catheterization.
Left ventriculography.
Left internal mammary graft angiography.
Vein graft angiography.
Coronary angiography.
Percutaneous coronary intervention with angioplasty and drug eluting stent
treatment of circumflex disease stenosis and additional drug eluting stent
treatment of severe left main coronary artery stenosis and disease.
DESCRIPTION OF PROCEDURE
The patient was brought to emergently from the Emergency Department and after
consent was obtained, a six French sheath was placed in the right common
femoral artery under fluoroscopic guidance. A six French Judkins diagnostic
left coronary catheter was then utilized for left coronary angiography. The
right coronary angiography was performed with a Judkins right coronary catheter
as well as vein graft angiography and left internal mammary graft angiography.
After identification of the critical culprit lesion at previously stented
osteal or proximal circumflex, there was additional progressive disease culprit
lesion in the mid circumflex, below the stented segment, as well as severe
restenosis in the left main coronary artery separately. An EBU 3.75 guiding
catheter was then advanced into the left main coronary artery and a coronary
wire was advanced into the distal circumflex. Angioplasty was performed with a
Boston Scientific Quantum, noncompliant high pressure balloon, initially a 2.75
by 12 millimeters balloon for the left main stenosis and across the ostium of
the circumflex. Additional opening of this segment was then performed with a
3.0 by 12 millimeters Quantum balloon after the first balloon ruptured.
Indeed, the second balloon ruptured. Thereafter, this segment was felt to be
adequately patent and a Boston Scientific Emerge balloon, 2.25 by 20
millimeters, was then easily passed into the mid circumflex and angioplasty was
performed of the denovo progressive stenosis culprit lesion. This was a 2.25 by
20 millimeters Emerge balloon. Stenting was then performed with initial
placement of a Boston Scientific Promus PREMIER drug eluting stent, 2.25 by 20
millimeters, overlapping with the previous proximal stent, extending into the
mid vessel. This would not quite advance all the way distally. This was
deployed and due to additional disease at the edge, a second 2.25 by 8
millimeters Boston Scientific Promus PREMIER drug eluting stent was deployed
with overlap extending slightly further into the mid circumflex. This entire
segment was then post dilated with the 2.25 millimeters Emerge and subsequently
the 3.0 millimeters Quantum balloon. Thereafter, further angioplasty was
performed of the left main stenosis with a 3.5 Quantum balloon. Thereafter, a
larger Boston Scientific Promus PREMIER drug eluting stent 3.5 by 20
millimeters was deployed for the left main stenosis and this stent was deployed
extending from the ostium of the left main to the bifurcation. There was
overlap with the previously placed stent. This entire segment was then post
dilated with a 3.5 by 12 millimeters Boston Scientific NC Quantum high pressure
balloon to 24 and 26 atmospheres. Finally without balloon rupture and with
excellent angiographic result after intracoronary nitroglycerin and withdrawal
of the balloon and wire. A six French pigtail catheter was then utilized for
left heart catheterization and left ventriculography. Ileofemoral angiography
confirmed the sheath in the common femoral artery and closure was obtained with
an Angio-Seal closure device. There were no complications.
HEMODYNAMICS
The intraaortic pressure was 135/70.
The left ventricular pressure was 135/20 with mildly elevated left ventricular
end diastolic pressure and no transaortic valvular gradient.
No left ventriculography was performed due to the large volume of contrast
necessary for the diagnostic angiography due to the patient's anatomy, grafts
and two vessel angioplasty as detailed above.
ANGIOGRAPHIC FINDINGS
The right coronary artery was known to be chronically occluded. There was no
graft to the distal right coronary artery. Those vessels do fill from distal
branches of the circumflex and possible left anterior descending.
The left main was calcified. There was a stent extending from the ostium of the
circumflex into the proximal circumflex. This stent did demonstrate some
moderate in stent restenosis. Below this stent, there was denovo lesions in
the mid circumflex up to 90 percent with hazy ulcerated plaque appearance. The
left main itself in several projections appeared to be patent but in the
cranial projection, had a subtotal occlusion ulcerated plaque as well. This
was a brand new lesion from the March 2014 angiogram. This was a nondominant
but large distal distribution circumflex which did collateralize the distal
right coronary artery. The left anterior descending despite the stent, in the
left main and the circumflex, remained patent proximally and there was
competitive filling of this mid vessel through a patent mammary graft. The left
internal mammary graft to the mid left anterior descending was widely patent.
The vein graft to the major diagonal was widely patent with a widely patent
stent in the vessel as well. No change was noted angiographically.
Intervention as described above, successful angioplasty and stenting with drug
eluting stenting performed of the mid circumflex new lesion, with overlap of
the previously placed proximal circumflex stent and additionally the left main
coronary angioplasty and large drug eluting stent placement were performed for
the left main stenosis.
SUMMARY AND CONCLUSIONS
1. Chest pain, acute coronary syndrome and acute myocardial infarction with
acute posterior wall infarction.
2. Critical lesions in the mid circumflex and left main coronary artery, each
treated with drug eluting stent placement.
3. Patent mammary graft to the left anterior descending and vein graft to the
major diagonal.
4. Chronically occluded right coronary artery with collaterals.
5. Moderately elevated left ventricular end diastolic pressure.
RECOMMENDATION
Aggressive risk factor modification, aspirin and Clopidogrel duel antiplatelet
therapy.
should i do 93459-xu,c9606,c9601 or 93459-xu, c9606,c9600 i am hospital coder. thanks in advance