1. Coronary angiography.
2. Left heart catheterization.
3. Selective right subclavian and right brachiocephalic angiography.
4. Nonselective limited angiography involving left subclavian, left common carotid arteries.
After obtaining informed consent, the patient was prepped and draped in sterile fashion. A 6 French glide sheath was inserted in the right radial artery. 5 French Jacky radial coronary catheter was used for left and right coronary angiography and left ventricular pressure assessment and right brachiocephalic and right subclavian angiography. A transradial band was then used for hemostasis.
I attest that moderate conscious sedation was provided under my direct supervision with the sedation trained nurse using 50 mcg of fentanyl to sedate the patient. Start time 12:24 pm and end time was 12:54 for a total of 30 minutes. There were no complications. See nurse's sedation sheet, for complete pre-and post service details.
The left ventricular end diastolic pressure was 6 mmHg. The trans-aortic gradient was 0 mmHg.
Right coronary artery: Large caliber diffusely ectatic dominant vessel with tandem 90% calcified stenotic lesions. It gives off RPDA and RPL branches.
Left Main: Large caliber vessel with distal 80% stenosis. It gives rise to LAD, LCx and ramus intermedius.
Left anterior descending: Large caliber with proximal ectasia followed by 90% calcified mid segment stenosis followed by early distal segment CTO . Distal LAD is moderate in caliber and seen filling via left to left collaterals. LAD also gives off diagonal and septal branches.
Left circumflex: Moderate caliber nondominant vessel with mid segment ectasia and 40 to 50% mid segment stenosis, gives off OM and LPL branches.
Ramus intermedius: Is a moderate caliber vessel with proximal ectasia and 40% mid segment stenosis.
No significant stenosis involving the proximal left subclavian artery, proximal left common carotid artery, 40 to 50% stenosis with no significant gradient involving distal right brachiocephalic artery, no significant stenosis involving proximal right common carotid and right subclavian arteries.
The patient was then transferred to the recovery area in stable condition:
1. Severe multivessel CAD involving distal left main, mid LAD, ramus intermedius, LCx, proximal RCA.
2. Low normal LVEDP with no significant transaortic gradient.
3. Moderate distal right brachio-cephalic stenosis with no significant pressure gradient.
1. CT surgical evaluation for revascularization.
2. Guideline directed medical therapy. Aggressive risk factor modification.
thank you in advance
I am coming up with 93458, 36215-rt or should I do 93458, 36216-rt?