bhargavi
Guru
After obtaining informed consent, the patient was prepped and draped in sterile fashion. The patient was placed under MAC anesthesia. Bilateral groins were exposed. Under fluoroscopic guidance and using modified subcutaneous technique, a long 6 French arterial and 6 French venous sheath were placed in the right femoral artery and vein, respectively by me. Simultaneously, cutdown was performed by Drs. Szydlowski and Dr. Marelli and left carotid artery was exposed. A short 6 French sheath was then placed into the left common carotid artery. Following this, a 5 French balloon tipped unipolar pacing catheter was advanced into the right ventricle. Capture was confirmed at a rate of 80 bpm and at a minimum output of 0.6 mA. Position was confirmed both fluoroscopically and echocardiographically. We then obtained a 5 French marker pigtail catheter which was positioned in the right coronary cusp of the aortic valve. A coplanar view of 5degrees LAO and 0 degrees caudal was obtained, which confirmed aortic valve position.
A 5 French FR4 diagnostic catheter was then advanced through the 6 French sheath over a standard procedural wire into the ascending aorta. The procedural wire was withdrawn and exchanged for a 280 cm Cook wire which was used to cross the aortic valve. FL 4 catheter was advanced across the aortic valve into the left ventricle and Cook wire was withdrawn and exchanged for 280 cm Amplatz superstiff wire with an extra curve into the apical left ventricle. The diagnostic catheter and short 6 French arterial sheath were then removed. We obtained a 16 French Edwards commander sheath which was advanced without difficulty into the ascending aorta.
20,000 units of intravenous heparin was administered by bolus, with an activated clotting time of greater than 300 seconds. We then obtained by deployment system for a 29 Edwards Sapien transcatheter aortic valve delivery system. This was advanced without difficulty into the ascending aorta. Commander sheath was slightly withdrawn to expose the valve. The deployment balloon was with drawn into the undeployed valve after parallax was withdrawn. We then advanced the loaded stent across the stenotic aortic valve. After confirmation of positioning fluoroscopically utilizing ascending aortography, the valve was deployed over 4 seconds to nominal pressure. Pacing was initiated at 180 bpm, which allowed for achievement of systolic blood pressure of 50 mmHg or less with a pulse pressure of less than 10 mmHg. After this, the valve was deployed. The valve apparatus was then withdrawn into the descending thoracic aorta. A transthoracic echocardiogram performed immediately after valve deployment revealed excellent valve position with no paravalvular leak. There was no evidence of any vascular complication and no evidence of pericardial effusion. We performed confirmatory ascending aortography which revealed excellent valve position at 80% aortic 20% ventricular on the left coronary cusp side and 85 % aortic and 15 % ventricular on noncoronary cusp side. Hemodynamics were excellent, so we decided to remove the working wire and valve deployment apparatus. The pacing catheter was removed as well.
We then removed the commander sheath and effected closure of the arteriotomy via suture was performed by Drs. Marelli and Sadlowski. We then performed digital subtraction angiography of the aortic arch pigtail catheter. Selective angiography of right common carotid and internal carotid artery was performed using a FL 4 diagnostic catheter which revealed patent right common carotid artery with evidence of retrograde dissection which was nonflow limiting. Angiography of the right iliofemoral system revealed a widely patent and large right iliofemoral system with no evidence of vascular injury. Mynx vascular closure device was deployed in right common femoral artery access site. The long venous sheath was removed with manual compression for hemostasis.
The patient was then transferred to the cardiovascular intensive care unit in stable condition.
thanks in advance
approach is carotid and there are no cpts for carotid approach should i bill unlisted procedure?
A 5 French FR4 diagnostic catheter was then advanced through the 6 French sheath over a standard procedural wire into the ascending aorta. The procedural wire was withdrawn and exchanged for a 280 cm Cook wire which was used to cross the aortic valve. FL 4 catheter was advanced across the aortic valve into the left ventricle and Cook wire was withdrawn and exchanged for 280 cm Amplatz superstiff wire with an extra curve into the apical left ventricle. The diagnostic catheter and short 6 French arterial sheath were then removed. We obtained a 16 French Edwards commander sheath which was advanced without difficulty into the ascending aorta.
20,000 units of intravenous heparin was administered by bolus, with an activated clotting time of greater than 300 seconds. We then obtained by deployment system for a 29 Edwards Sapien transcatheter aortic valve delivery system. This was advanced without difficulty into the ascending aorta. Commander sheath was slightly withdrawn to expose the valve. The deployment balloon was with drawn into the undeployed valve after parallax was withdrawn. We then advanced the loaded stent across the stenotic aortic valve. After confirmation of positioning fluoroscopically utilizing ascending aortography, the valve was deployed over 4 seconds to nominal pressure. Pacing was initiated at 180 bpm, which allowed for achievement of systolic blood pressure of 50 mmHg or less with a pulse pressure of less than 10 mmHg. After this, the valve was deployed. The valve apparatus was then withdrawn into the descending thoracic aorta. A transthoracic echocardiogram performed immediately after valve deployment revealed excellent valve position with no paravalvular leak. There was no evidence of any vascular complication and no evidence of pericardial effusion. We performed confirmatory ascending aortography which revealed excellent valve position at 80% aortic 20% ventricular on the left coronary cusp side and 85 % aortic and 15 % ventricular on noncoronary cusp side. Hemodynamics were excellent, so we decided to remove the working wire and valve deployment apparatus. The pacing catheter was removed as well.
We then removed the commander sheath and effected closure of the arteriotomy via suture was performed by Drs. Marelli and Sadlowski. We then performed digital subtraction angiography of the aortic arch pigtail catheter. Selective angiography of right common carotid and internal carotid artery was performed using a FL 4 diagnostic catheter which revealed patent right common carotid artery with evidence of retrograde dissection which was nonflow limiting. Angiography of the right iliofemoral system revealed a widely patent and large right iliofemoral system with no evidence of vascular injury. Mynx vascular closure device was deployed in right common femoral artery access site. The long venous sheath was removed with manual compression for hemostasis.
The patient was then transferred to the cardiovascular intensive care unit in stable condition.
thanks in advance
approach is carotid and there are no cpts for carotid approach should i bill unlisted procedure?