bhargavi
Guru
Indications
Conclusion
thanks in advance but I came up with 37215, 61650, 61630, 37211 75898, 76937 but there are cci column1 and column 2 edits 61650-37215, 61630-37211
Carotid artery occlusion without infarction, unspecified laterality [I65.29 (ICD-10-CM)] |
Conclusion
Report for: Transfemoral approach diagnostic angiogram cerebral with angioplasty and stenting of the right internal carotid artery previous stent 10 years ago stenosis/occlusion using distal protection device Reason for angiogram: Patient with previous right internal carotid artery stent 10 years ago had almost near occlusion on CT angiogram of the stent. Brief history: Patient with complicated medical history of HTN, CVA, with previous stenting of his right internal carotid artery, CKD, CHF, history of coronary artery disease status post CABG who was evaluated outpatient by his cardiology who found that he almost has near occlusion of the right carotid artery in-stent stenosis versus thrombosis. Patient was feeling dizzy lightheaded patient was scheduled for urgent procedure. Informed consent: The procedure was explained to the patient in layman terms. Multiple images and diagrams were used to explain the procedure. The risk of the procedure which includes but not limited to groin hematoma, retroperitoneal hematoma, contrast neohropathy, Major and minor stroke, vascular dissection and death was explained to the patients in layman terms. All questions were appropriately answered, patient and patient family elected to have the above procedure performed. Patient was loaded with 325 mg aspirin and 300 mg Plavix in the morning prior to the procedure. Anesthesia: conscious sedation: Patient was placed on continuous hemodynamic monitoring and direct face to face observation was done during the procedure for over 60 plus minutes. Conscious sedation administration using 2 mg Versed and 50mcg fentanyl was done. Continue monitoring and direct management of conscious sedation was done by me during whole procedure and post procedure Procedures performed:
2. Conscious sedation for duration of more than 60 minutes with direct face-to-face observation and monitoring of the patient. 3. Right internal carotid artery angiogram head and neck. 4. Catheterization of right internal carotid artery using distal protection device Angioguard 5 mm medium support 5. Balloon angioplasty x4 pre-and post stenting using distal protection device with balloon measuring 4 x 15 mm. 6. Stenting of right internal carotid artery using precise carotid stent 7 x 40 mm. 7. Angiogram of right t internal carotid artery post angioplasty and stenting of the head and neck. 8. Intra-arterial left internal carotid artery 10 mg Integrilin bolus infusion through existing catheter in right internal carotid artery 9. Angiogram of right internal carotid artery post infusion of Integrilin. 10. Angiogram of right common femoral artery and using closure device for arteriotomy Angio-Seal 6 French. Description of procedure: patient was brought to angio suite and identified using multiple patient identifiers. Time out was performed by entire team. Patient was placed in supine position on angiography table and bilateral ground and right wrist was cleaned using beta fine solution. Sterile drape was applied. Right femoral artery was palpated and under ultrasound 6 French sheath was placed using micro puncture kit and modified Seldinger technique using ultrasound. This was sutured and continuously flushed with pressurized heroism saline. A 6 French ENVOY base catheter was continuously flushed with heparinized swine and was then navigated over 0.035 guidewire up to arch of aorta where it was reconstituted and following blood vessels were catheterized-right common carotid artery. The angiogram was analyzed which demonstrated almost severe stenosis with a fresh noncalcified thrombus. At this time ACT was checked and patient was given heparin bolus to keep and maintain the ACT above 300. Distal protection device Angioguard was prepared and using fluoroscopy and roadmapping technique distal protection device was navigated through stenotic area along with using distal protection device wire, distal protection device was deployed at the straight distal cervical segment without any complication. Angiogram was done which showed some stasis of the flow due to critical stenosis and near occlusion following distal protection device deployment. At this point aviator balloon measuring 4 x 15 mm was navigated using roadmapping and fluoroscopic technique over distal protection device wire. Balloon was deployed at critical stenotic area and 10 mm pressure was applied for angioplasty. At the area of the stent 3 times angioplasty was done using aviator balloon. once balloon was deflated angiogram was done which showed good results of angioplasty and at that time balloon was taken out. At that point angiogram showed occlusion of the right internal carotid artery with stent thrombosis. Patient was given 10 mg intra-arterial Integrilin through the existing catheter into the right internal carotid artery stented area. After infusion angiogram demonstrated good flow of the right internal carotid artery through the stent. At this point it was decided to deploy a stent to avoid closure of the artery. A precise carotid stent measuring 7 x 40 mm was deployed using roadmapping of fluoroscopic technique. The stent deployment system was taken out and angiogram was done which showed s mild stenosis in the stenting area with a flow stagnation, at that time 4 x 15 mm balloon was taken over distal protection device prior and post stent deployment angioplasty was done. The end result showed degree of stenosis prior to angioplasty and stenting less than 30% as per NASCET criteria. Once the desired results were achieved all catheters were taken out and her arteriotomy site was closed with Angio-Seal device. Complications - None Disposition- patient was admitted to neuro ICU for further management and recovery. Interpretation : Right internal carotid artery angiogram, neck and head -angiogram of the right internal carotid artery demonstrated more than 70% degree of the left internal carotid artery at the bifurcation as per NASCET criteria along with non-calcified thrombus/plaque at the stent.. The flow to the right external carotid artery appears normal along with normal-appearing external carotid artery branches. The flow distal to the stenotic area is sluggish and slow and there is a delayed filling of the rest of the internal carotid artery. The intracranial portion of right internal carotid artery ends into right middle cerebral artery and right anterior cerebral artery which appears normal. Right internal carotid artery angiogram neck and head post angioplasty and stenting: Right internal carotid artery angiogram post angioplasty and stenting demonstrate good results with a good perfusion of the rest of the right internal carotid artery both extracranial and intracranial portion. The degree of stenosis post angioplasty and stenting is less than 30% as per NASCET criteria. The right t external carotid artery also appears normal with normal-appearing branching. After angioplasty there was some stagnation of flow and occlusion of the right internal carotid artery at the level of stenting at that point 10 mg intra-arterial Integrilin was injected through the existing catheter which resulted in good flow of the vessel. Post infusion of Integrilin showed good filling of the internal carotid artery including intracranial portion and middle cerebral artery and anterior cerebral artery. The capillary, venous phase of the above-mentioned artery all appears normal. Right common femoral artery angiogram- Right CFA angiogram demonstrate normal appearing right CFA proximally with normal bifurcation. The site of arteriotomy appears well above bifurcation of CFA. Impression: 1. Angiogram demonstrated severe stenosis of the previously stented portion of the right internal carotid artery with noncalcified plaque/thrombus at the stent level. 2. Patient underwent successful angioplasty and stenting of the right internal carotid artery using distal protection device with a good outcome. Plan: Patient will be admitted to neuro ICU for further monitoring and management. Patient will be placed on Integrilin drip at the rate of 1 MCG per KG per minute over next 12 hours since patient has double stent and also he is a high risk for clot formation . Patient will continue take 325 mg aspirin and 75 Plavix along with the Lipitor and good blood pressure control. Upon discharge from the hospital patient will be seen in neuro interventional clinic as a follow-up in next 1 to 2 weeks. |