Wiki PTCA with "embolization of thrombus" found and treated

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Lonaconing, MD
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(This is profee) I got the following codes: Dx: I25.10, I25.84, E74.39, I82.409, Z79.01
Procedure codes: 93454-26, XU 92928-LD 92929-LD 99152

I am not sure what to code for the portion of the report that speaks of the embolization of thrombus:

"There was evidence of distal embolization of thrombus, and we were performed subsequent
gentle balloon inflations of the distal LAD with a 2.5 mm and 2.0 mm balloon up
to 6 atmospheres with resolution of the thrombus. The patient did receive an
intracoronary bolus of Integrilin due to the thrombus burden."


This is the report in it's entirety:


INDICATIONS: Patient is an 80-year-old gentleman with a past medical history
significant for impaired glucose tolerance and deep venous thrombosis (on
Coumadin) who presented with syncope and was noted to be bradycardic. He
underwent a treadmill stress test to evaluate for chronotropic incompetence
which was negative however he had ST depression and shortness of breath. He
underwent a coronary CT angiogram which revealed severe 3-vessel coronary
artery disease and was referred for cardiac catheterization.

PROCEDURES PERFORMED:
1. Coronary angiography
2. PTCA/Stent of the mid LAD with a Xience DES
3. PTCA/Stent of the proximal Frist Diagonal with a Xience DES
4. Moderate conscious sedation
5. Radial artery approach

Administration, documentation and physiologic monitoring of IV conscious
sedation was performed under my direct supervision with a trained nurse from
08:03 a.m. to 09:17 a.m.; intraservice time 75 minutes.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was
prepped and draped in the usual sterile fashion. He was premedicated with 2 mg
of Versed and 50 mcg of fentanyl. Local anesthesia was obtained with 1 mL of
2% lidocaine. A 6-French slender radial sheath was placed in the right radial
artery by the modified Seldinger technique utilizing a micropuncture needle.
Diagnostic cardiac catheterization was performed using a 5-French Jacky
catheter and selective angiography of the left coronary system and RCA were
obtained in multiple projections. The coronary angiograms were reviewed and it
was determined to proceed with percutaneous coronary intervention of the LAD
and diagonal branch with plans for staged PCI of the RCA.

DESCRIPTION OF THE CORONARY INTERVENTION: A 6-French 3.5 EBU guide catheter
was advanced over an exchange length wire to the left main coronary ostium.
Heparin bolus 4000 additional units was given for an ACT greater than 300. A
0.014 Prowater guidewire was advanced across the lesion within the proximal
diagonal branch into the distal artery. A 0.014 Sion blue guidewire was
advanced across the lesion within the mid LAD into the distal artery. We then
advanced a 2.5 mm x 12 mm balloon to the mid LAD and inflated it up to 16
atmospheres. This was removed and we advanced a 3.5 mm x 15 mm Xience
drug-eluting stent and deployed it in the mid LAD at 12 atmospheres. The stent
was then postdilated with a 3.75 mm x 12 mm noncompliant balloon up to 16
atmospheres and proximally with a 4.0 mm x 8 mm noncompliant balloon up to 16
atmospheres. There was evidence of some distal embolization of thrombus into
the distal LAD and we did gentle balloon inflations in the distal LAD with a
2.5 mm balloon as well as a 2.0 mm balloon up to 6 atmospheres. In addition,
the patient did receive an intracoronary bolus of Integrilin. We then
proceeded with percutaneous coronary intervention of the diagonal branch and we
advanced a 2.5 mm x 12 mm balloon into the proximal diagonal branch and
inflated it up to 12 atmospheres. This was removed and we advanced a 3.0 mm x
12 mm Xience drug-eluting stent and deployed it at 10 atmospheres. The stent
was then postdilated with a 3.25 mm x 8 mm noncompliant balloon up to 16
atmospheres. Final angiograms revealed an excellent result with 0% residual
stenosis. The guidewire, guide catheters and introducer sheaths were removed
and hemostasis was obtained with a TR band. There were no complications.

FINDINGS:
HEMODYNAMICS: Aortic pressure 141/79 mean 107

CORONARY ANATOMY: The Left Main has no significant disease. The left anterior
descending artery has proximal 30% disease followed by a mid 80% stenosis and a
distal 50% disease. It gives off a large diagonal branch with a proximal 90%
stenosis, a tiny second diagonal branch with an ostial 90% stenosis, and a
small third diagonal branch with no significant disease. The left circumflex
has ostial/proximal 30-40% disease. It gives off a large obtuse marginal
branch with mid 40% disease. The right coronary artery is calcified with
proximal 70% disease followed by distal 70-80% stenosis.

CONCLUSIONS:
1. The Left Main has no significant disease.
2. The LAD has proximal 30% disease followed by a mid 80% stenosis and distal
50% disease. It gives off a large first diagonal branch with a proximal 90%
stenosis, a tiny second diagonal branch with an ostial 90% stenosis, and a
small third diagonal branch with no significant disease.
3. The LCX has ostial/proximal 30-40% disease. It gives off a large obtuse
marginal branch with mid 40% disease.
4. The RCA is dominant with a proximal calcified 70% stenosis followed by a
distal 70-80% disease.
5. Successful PTCA/Stent of the mid LAD with a 3.5mm x 15mm Xience drug eluting
stent (postdilated up to 4.0 mm proximally) from 80% to 0% residual. There was
evidence of distal embolization of thrombus and we were performed subsequent
gentle balloon inflations of the distal LAD with a 2.5 mm and 2.0 mm balloon up
to 6 atmospheres with resolution of the thrombus. The patient did receive an
intracoronary bolus of Integrilin due to the thrombus burden.
6. Successful PTCA/Stent of the proximal First Diagonal with a 3.0mm x 12mm
Xience drug eluting stent (postdilated up to 3.25 mm) from 90% to 0% residual.

RECOMMENDATIONS:
1. Triple therapy (aspirin 81mg, Plavix 75mg and Coumadin) for 2-4 weeks at
which point the aspirin can be discontinued.
2. Staged PCI of the RCA as an outpatient, which will likely need atherectomy
due to the heavy calcification.
 
Thrombus broke off from the intervention of the LD, so the doctor compressed the clot against the wall of the vessel to reopen the vessel. No embolization was performed.
HTH,
Jim Pawloski, CIRCC
 
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