bhargavi
Guru
PROCEDURES
1. Coronary angiogram
2. Left heart catheterization
3. Graft angiogram
4. Percutaneous intervention and balloon angioplasty of vein graft to OM1.
5. Right iliofemoral angiogram
PROCEDURE NOTE
Informed consent was obtained after explaining risks and benefits to the patient. Right groin was draped and prepped in a sterile fashion. Patient was premedicated with 1.5 mg Versed and 100 mcg fentanyl IV. After injecting 2% lidocaine, right common femoral artery was accessed with the help of micropuncture with some difficulty due to previous scarring and 6 French femoral sheath was inserted. 6 French diagnostic catheters were used to cannulate left and right coronary artery. 6 French FR 4 catheter was also used to cannulate the vein grafts. Patient was proceeded with intervention of the vein graft of obtuse marginal branch. Overall patient tolerated procedure well. Right iliofemoral angiogram was performed and femoral sheath was pulled and manual pressure was applied for 20 minutes with good hemostasis. FemoStop was applied at Bell pressure for persistent hemostasis.
*
LEFT HEART CATHETERIZATION
Left ventricular end diastole pressure was 18 mmHg. No significant gradient across aortic valve.
CORONARY ANGIOGRAM
1. Left main was calcified with 70-80% distal stenosis.
2. Left anterior descending artery had severe diffuse disease proximally before it was 100% occluded for previous stents
3. Left circumflex artery was 100% occluded proximally
4. Right coronary artery was under percent occluded at the origin.
*
GRAFT ANGIOGRAM
1. Vein graft to LAD was under percent occluded (chronic)
2. Vein graft to RCA was patent. Stent was noted in the mid body of the graft which was patent with 80% in-stent restenosis. 50-60% stenosis noted in distal RCA after anastomosis before the bifurcation of PDA and PLV branches. PDA branch was patent with no significant disease given collaterals to distal LAD. PLV branch was patent.
3. Vein graft to obtuse marginal branch was patent with TIMI II antegrade flow. Stent at the ostium had 99% in-stent restenosis. There was also 80-90% stenosis of mid part of the body of the graft within the previous stent. Distal part of the vein graft was patent.
*
PERCUTANEOUS INTERVENTION OF VEIN GRAFT OBTUSE MARGINAL BRANCH
6 French JR4 guide catheter was used to cannulate the vein graft to OM 1. Heparin was used for anticoagulation. Initially filter wire was attempted for distal protection which was unsuccessful to advance due to significant ostial stenosis. 0.014 BMW guidewire was advanced and vein graft to OM stenosis was successfully crossed without difficulty. 2.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft was predilated at 16 followed by 18 atm. Nitroglycerin intracoronary was given. Subsequent angiogram revealed TIMI-3 antegrade flow and distal part of the body of the graft but still residual significant stenosis at the ostium. 3.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft were dilated at 16 atm couple of times. Adenosine followed by nitroglycerin were given through guide catheter. Subsequent angiogram revealed wide-open vein graft to OM with TIMI-3 antegrade flow and no evidence of dissection or perforation. No evidence of distal embolization. Patient was hemodynamically stable and asymptomatic at the end of procedure.
RIGHT ILIOFEMORAL ANGIOGRAM
Right common femoral artery was patent. Sheath insertion was just below the origin of the inferior epigastric artery..
IMPRESSION
1. Severe native 3 vessels coronary artery disease.
2. Patent vein graft to OM1 with 99% ostial stenosis within the stent as well as 80% instent restenosis within the mid body of the graft. (Likely culprit)
3. Patent vein graft to RCA with 80% in-stent restenosis.
RECOMMENDATIONS
Patient has complex coronary disease as described above. He had multiple intervention of vein graft in the past including 3 intervention in vein graft to OM last year. He has significant instent restenosis of drug-eluting stents. Recommend evaluation by cardiac surgery for possible redo CABG. Continue aggressive medical treatment.
*
should I do 93459,92937 -lc since this is vein graft balloon angio or 92920? I bill for hospital
thanks in advance
1. Coronary angiogram
2. Left heart catheterization
3. Graft angiogram
4. Percutaneous intervention and balloon angioplasty of vein graft to OM1.
5. Right iliofemoral angiogram
PROCEDURE NOTE
Informed consent was obtained after explaining risks and benefits to the patient. Right groin was draped and prepped in a sterile fashion. Patient was premedicated with 1.5 mg Versed and 100 mcg fentanyl IV. After injecting 2% lidocaine, right common femoral artery was accessed with the help of micropuncture with some difficulty due to previous scarring and 6 French femoral sheath was inserted. 6 French diagnostic catheters were used to cannulate left and right coronary artery. 6 French FR 4 catheter was also used to cannulate the vein grafts. Patient was proceeded with intervention of the vein graft of obtuse marginal branch. Overall patient tolerated procedure well. Right iliofemoral angiogram was performed and femoral sheath was pulled and manual pressure was applied for 20 minutes with good hemostasis. FemoStop was applied at Bell pressure for persistent hemostasis.
*
LEFT HEART CATHETERIZATION
Left ventricular end diastole pressure was 18 mmHg. No significant gradient across aortic valve.
CORONARY ANGIOGRAM
1. Left main was calcified with 70-80% distal stenosis.
2. Left anterior descending artery had severe diffuse disease proximally before it was 100% occluded for previous stents
3. Left circumflex artery was 100% occluded proximally
4. Right coronary artery was under percent occluded at the origin.
*
GRAFT ANGIOGRAM
1. Vein graft to LAD was under percent occluded (chronic)
2. Vein graft to RCA was patent. Stent was noted in the mid body of the graft which was patent with 80% in-stent restenosis. 50-60% stenosis noted in distal RCA after anastomosis before the bifurcation of PDA and PLV branches. PDA branch was patent with no significant disease given collaterals to distal LAD. PLV branch was patent.
3. Vein graft to obtuse marginal branch was patent with TIMI II antegrade flow. Stent at the ostium had 99% in-stent restenosis. There was also 80-90% stenosis of mid part of the body of the graft within the previous stent. Distal part of the vein graft was patent.
*
PERCUTANEOUS INTERVENTION OF VEIN GRAFT OBTUSE MARGINAL BRANCH
6 French JR4 guide catheter was used to cannulate the vein graft to OM 1. Heparin was used for anticoagulation. Initially filter wire was attempted for distal protection which was unsuccessful to advance due to significant ostial stenosis. 0.014 BMW guidewire was advanced and vein graft to OM stenosis was successfully crossed without difficulty. 2.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft was predilated at 16 followed by 18 atm. Nitroglycerin intracoronary was given. Subsequent angiogram revealed TIMI-3 antegrade flow and distal part of the body of the graft but still residual significant stenosis at the ostium. 3.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft were dilated at 16 atm couple of times. Adenosine followed by nitroglycerin were given through guide catheter. Subsequent angiogram revealed wide-open vein graft to OM with TIMI-3 antegrade flow and no evidence of dissection or perforation. No evidence of distal embolization. Patient was hemodynamically stable and asymptomatic at the end of procedure.
RIGHT ILIOFEMORAL ANGIOGRAM
Right common femoral artery was patent. Sheath insertion was just below the origin of the inferior epigastric artery..
IMPRESSION
1. Severe native 3 vessels coronary artery disease.
2. Patent vein graft to OM1 with 99% ostial stenosis within the stent as well as 80% instent restenosis within the mid body of the graft. (Likely culprit)
3. Patent vein graft to RCA with 80% in-stent restenosis.
RECOMMENDATIONS
Patient has complex coronary disease as described above. He had multiple intervention of vein graft in the past including 3 intervention in vein graft to OM last year. He has significant instent restenosis of drug-eluting stents. Recommend evaluation by cardiac surgery for possible redo CABG. Continue aggressive medical treatment.
*
should I do 93459,92937 -lc since this is vein graft balloon angio or 92920? I bill for hospital
thanks in advance