Peripheral and LHC

rparikh

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Should I be using codes: 93458-26, 75630-26, 75605-26, 36245, 92980-LD, and 37221

Procedures :


1. Selective Left and Right coronary angiography.
2. Left-sided hemodynamic measurements.
3. Left ventriculography
4. Aortic Arch Angiography
5. DSA of abdominal aorta with run off
6. Left iliac, left common femoral, and left SFA angiography by first order method
7 DSA of left leg by second order method
8. Angiography of right femoral artery by first order method with distal run off to the legs
9. DSA of right leg by third order method
10 . Successful PCI of proximal LAD in-stent restenosis with 3x18 Xience DES
11. Successful PCI of Right common iliac artery with angioplasty followed by stenting with Medtronic 10x40mm self expanding stent




DESCRIPTION OF PROCEDURE:


After obtaining informed consent, the patient was brought to the cardiac catheterization lab. Both groins were prepped and draped in the usual sterile fashion. Caps, masks, sterile gowns and sterile gloves were worn prior to the initiation of the procedure and universal precautions were strictly observed.


After obtaining adequate local anesthesia with infiltration of the right groin with 1% lidocaine, a standard 6 French sheath was inserted into the Right femoral Artery by modified Seldinger technique using a Cook needle. The sheath was appropriately flushed.


A ttempts to advance a regular J wire past the right external iliac into the aorta were unsuccesful. Right femoral angiography was then performed. An angled glide wire was then manipulated over a JR4 catheter across the obstruction in the right external iliac. Selective right coronary angiography was then done and images were acquired in various projections. The catheter was then exchanged for a JL4 catheter over a regular J wire and selective left coronary angiography was performed and images were acquired in various projections. The catheter was then exchanged for a pigtail catheter over a guidewire . LV gram as well as LV pressure measurements were performed using this pigtail catheter. After obtaining pullback pressure thoracic aortography was done and images were acquired. The pigtail catheter was then removed over a wire.


After reviewing angiographic images decision was taken to intervene on the the significant in-stent restenosis of proximal LAD stent. Angiomax and integrilin bolus were given and angiomax drip was started. An EBU 4.0 guide was used to engage the LCA. A short intuition guide wire was advanced through the LM across the LAD stent and placed in the distal LAD. Direct stenting of the stenotic area was done with a 3x18 mm Xience DES to 10 atm. Post dilation was done with a 3.5x12 NC balloon with multiple inflation ranging from 12 to 18 atm (distal to proximal). Balloon and wire were then removed and final angiographic images were acquired. The guide catheter was then removed over a wire.


The pigtail catheter was then advanced back into the abdominal aorta and DSA of Abdominal aorta was done. The catheter was then removed over a wire and 5mmx40mm peripheral balloon was used to perform angioplasty of the 90% stenosis of proximal right common iliac artery with multiple inflations to 8 atm. Repeat angiographic images of the right common iliac showed persisting 70-80% stenosis post balloon angioplasty. Hence a 10x40 mm Medtronic self expanding stent was deployed over the stenotic area. Post dilation was done with a 10x20mm balloon with multiple inflations to 4-5 atm. Balloon catheter was then removed.


Right f emoral arteriography was distal run off was then performed . Next a contra-catheter was inserted over a wire and advanced into the proximal left iliac. Common iliac angiography was done. The catheter was then advanced into SFA and angiography of SFA, popliteal and tibio-peroneal vessels was done. The catheter was then removed.


Femoral sheath was left in place for subsequent removal in the recovery unit.


COMPLICATIONS:
None


ESTIMATED BLOOD LOSS:
The estimated blood loss was 3 0 ml


TOTAL FLUOROSCOPY TIME:
27.6 minutes


TOTAL CONTRAST USED:
425 ml Visipaque


HEMODYNAMIC FINDINGS:


Aortic Pressure: 159/65 mmHg
LVSP: 159 mmHg
LVEDP: 18 mmHg
No gradient across aortic valve on catheter pull back.


ANGIOGRAPHIC FINDINGS:


1. Left Main coronary artery is a medium size vessel. It gives rise to Left Anterior Descending artery and Left Circumflex rtery. There is mild disease involving the proximal and mid segments of the left main.
No significant lesions noted.
2. Left Anterior descending artery is a large size vessel. It gives rise to multiple septal and diagonal branches. There is mild 20-30% stenosis of the proximal LAD at the proximal edge of the stent in LAD. Severe 90% focal in-stent restenosis is seen near the distal end of the stent. The first diagonal is a medium to small vessel with multiple stenotic lesions from proximal to distal varying from 70-80% in severity. Collaterals are seen from the LAD to the RCA.
3. Left circumflex artery is a medium size non dominant vessel. It gives rise to multiple small obtuse marginal branches.
No significant lesions are noted.
4. Right coronary artery is of small caliber with mild to moderate disease in the proximal and mid segments. The vessel is completely occluded after the take off of the acute marginal branch. a large dominant vessel.
5. . LV gram showed normal LV size and function. Estimated ejection fraction of 65%. No mitral regurgitation is present.
6. Aortogram showed normal size aortic root, normal appearing valve and leaflet mobility. No Aortic regurgitation is seen. There is mild fusiform aneurysmal dilation of the aortic arch prior to take off the innominate artery. A saccular aneurysm is seen at the proximal origin of the right internal carotid artery.
7. Abdominal aortography shows moderate size fusiform aneurysm involving the lower abdominal aorta proximal to aorto-iliac bifurcation.
8. Right iliac angiography shows moderate segmental stenosis all along the right common and external iliac with a severe 90% stenotic area in the proximal right common iliac.
8. Left iliac angiography showed mild to moderate stenosis along the common and external iliacs. Step down in systolic pressure of 20-30 mm Hg was noted from left common iliac to the left common femoral artery.
9. Angiography of the SFA and popliteal arteries showed mild to moderate stenosis along their course bilaterally.
10. Right leg angiography showed a two vessel run off with an completely occluded anterior tibial artery.
11. Left leg angiography shows a two vessel distal run off with a severely diseased anterior tibial proximally which is occluded completely in the mid to distal third of the leg.






Post PCI there was 20-30% focal stenosis in proximal LAD at the proximal end of the original stent that was unchanged. The distal in-stent restenosis had resolved with no residual stenosis and TIMI 3 flow was present.


Following PVI of the right common iliac artery the severe 90% proximal stenosis was reduced to 10% and good flow was present.


IMPRESSION AND CONCLUSIONS:
1. Two vessel coronary disease with CTO of right (with left to right collaterals) and severe in-stent restenosis of proximal LAD stent.
2 . Successful PCI of LAD ISR with 3x18 Xience DES
3 . Normal LV function
4. Peripheral vascular disease with severe 90% stenosis of right common iliac; s/p successful PVI of the lesion using 10x40 mm Medtronic self expanding stent
5. Moderate disease of both external iliac and common femoral arteries.
6. Two vessel run off in both legs with disease involving both anterior tibial arteries.
7. Saccular aneurysm of proximal right common carotid artery
8. Thoracic aortic aneurysm involving aortic arch proximal to innominate artery
9. Moderate size fusifom lower abdominal aortic aneurysm
 
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