Jane5711
Networker
I'm looking for some guidance on how the complications would be coded.
The report is as follows;
PCI OF PROXIMAL LAD WITH XIENCE DES:
Left main was engaged from radial approach with 6 French XB 3.5 guiding catheter, and then without significant difficulties I crossed the lesion with the 190 cm BMW Universal wire, which was advanced to the mid LAD, I have attempted to use 2.5 x 12 NC balloon, but it would not cross the lesion, so we used initially 2 x 12 mm regular balloon inflated at up to 12 atmospheres for 20 seconds, then we used 2.5 x 12 NC balloon inflated at up to 12 atmospheres for another 20 seconds, considering calcified lesion, and difficulties crossing a used shockwave 4 x 12 mm balloon, which we inflated up to 4 atmospheres and delivered for impulses, which showed excellent expansion of the balloon, and we followed with the positioning of 4 x 15 mm Xience DES which was deployed at nominal 12 atmospheres for 40 seconds, balloon was then withdrawn, and final angiogram was obtained, and showed excellent procedural result, full stent expansion and apposition, TIMI 3 flow to entire LAD, no extravasation, no dissection, 0% residual stenosis, no branches including septal were affected. Patient tolerated procedure well, and we started preparing to take the patient of the table.
PTCA ATTEMPT OF THE MID LAD FOR ACUTE CLOSURE:
About 8-10 minutes after completion of the 1st portion of this procedure patient developed 8/10 midsternal chest pain radiating to her jaw or and there was evidence of ST elevation on the EKG, we immediately obtained right femoral access, and initially used JL4 diagnostic catheter for left coronary angiogram, which showed widely patent proximal LAD stent, but occluded vessel from mid to distal LAD with TIMI 0 flow.
At this point I commenced acute intervention, and also called CTS Dr. was to prepare OR in case of failure, I suspected wire dissection, we checked ACT and patient was fully heparinized with ACT of 300, left main was engaged with XB 4 6 French guiding catheter, and then I 1st used universal BMW wire, which I was able to place slightly beyond the occlusion, with restoration of TIMI 1 flow to D2, and minimally to the LAD itself, however any additional attempts to advance the wire to the mid distal LAD and performed PCI were unsuccessful, and I used in addition whisper MS 190 cm wire, however the wire would travel in the dissection plane.
At this time OR was ready, patient actually improved with chest pain 3-4/10 in severity, and with mild improvement of ST elevation, prior to the PCI TIMI 0 flow, post PCI TIMI 1 flow.
CONCLUSIONS:
1. Single-vessel coronary artery disease with proximal-mid LAD 80% stenosis, PCI with 4 x 15 mm Xience DES and shockwave balloon angioplasty, complicated by dissection of the mid -distal LAD with acute vessel closure, and followed by unsuccessful PTCA.
2. Patient is already transferred, and will proceed with rescue CABG of LAD, will follow post surgery.
The report is as follows;
PCI OF PROXIMAL LAD WITH XIENCE DES:
Left main was engaged from radial approach with 6 French XB 3.5 guiding catheter, and then without significant difficulties I crossed the lesion with the 190 cm BMW Universal wire, which was advanced to the mid LAD, I have attempted to use 2.5 x 12 NC balloon, but it would not cross the lesion, so we used initially 2 x 12 mm regular balloon inflated at up to 12 atmospheres for 20 seconds, then we used 2.5 x 12 NC balloon inflated at up to 12 atmospheres for another 20 seconds, considering calcified lesion, and difficulties crossing a used shockwave 4 x 12 mm balloon, which we inflated up to 4 atmospheres and delivered for impulses, which showed excellent expansion of the balloon, and we followed with the positioning of 4 x 15 mm Xience DES which was deployed at nominal 12 atmospheres for 40 seconds, balloon was then withdrawn, and final angiogram was obtained, and showed excellent procedural result, full stent expansion and apposition, TIMI 3 flow to entire LAD, no extravasation, no dissection, 0% residual stenosis, no branches including septal were affected. Patient tolerated procedure well, and we started preparing to take the patient of the table.
PTCA ATTEMPT OF THE MID LAD FOR ACUTE CLOSURE:
About 8-10 minutes after completion of the 1st portion of this procedure patient developed 8/10 midsternal chest pain radiating to her jaw or and there was evidence of ST elevation on the EKG, we immediately obtained right femoral access, and initially used JL4 diagnostic catheter for left coronary angiogram, which showed widely patent proximal LAD stent, but occluded vessel from mid to distal LAD with TIMI 0 flow.
At this point I commenced acute intervention, and also called CTS Dr. was to prepare OR in case of failure, I suspected wire dissection, we checked ACT and patient was fully heparinized with ACT of 300, left main was engaged with XB 4 6 French guiding catheter, and then I 1st used universal BMW wire, which I was able to place slightly beyond the occlusion, with restoration of TIMI 1 flow to D2, and minimally to the LAD itself, however any additional attempts to advance the wire to the mid distal LAD and performed PCI were unsuccessful, and I used in addition whisper MS 190 cm wire, however the wire would travel in the dissection plane.
At this time OR was ready, patient actually improved with chest pain 3-4/10 in severity, and with mild improvement of ST elevation, prior to the PCI TIMI 0 flow, post PCI TIMI 1 flow.
CONCLUSIONS:
1. Single-vessel coronary artery disease with proximal-mid LAD 80% stenosis, PCI with 4 x 15 mm Xience DES and shockwave balloon angioplasty, complicated by dissection of the mid -distal LAD with acute vessel closure, and followed by unsuccessful PTCA.
2. Patient is already transferred, and will proceed with rescue CABG of LAD, will follow post surgery.