Wiki Revascularization attempt failed


Florence AL
Best answers
Any suggestions on the coding for the physician on this case?

1. LV catheter placement in the left ventricle with left ventriculography and hemodynamic measurements
2. Left main, LAD and circumflex coronary angiography
3. Attempted revascularization of the large ramus branch
4. Attempted revascularization of the left main, PTCA of the left main, cutting balloon of the left main, and Rotablator of the left main.

Indication: Nonsustained ventricular tachycardia and history of defibrillation

Description: Patient was prepped and draped in a sterile fashion. Access was gained via the right common femoral artery using ultrasound guidance. A 6-French sheath was placed. A 6-French catheter was placed across the aortic valve. LV pressure was 161/20,pullback pressure was 176/74. Next, injection of the left ventricle showed all walls moved, ejection fraction was greater than 50%.
Next, the left main coronary artery was cannulated with a 6-French XBLAD guide. The left main coronary artery had a severe heavily calcified distal lesion. LAD was being filled by LIMA and there is an occluded large ramus branch. Initially we attempted to revascularize the ramus branch, but this was not possible. A balloon was advanced into the lesion, but we could not advance the wire any further. Next, a wire was placed on the LAD______ initially, we tried balloon dilation. We used a 3.5x 11mm noncompliant Stormer at high pressure which was unsuccessful. Then we used a 3.5 x10 cutting balloon and we were unable to advance this past the lesion and then we used a 3.0x 10 cutting balloon at 12 atmospheres and again we were unsuccessful in dilating the lesion. A decision was made to use Rotablator. We upgraded to an 8-French sheath and multiple 8-French guides were used, but again we used the XBLAD guide and ______Rotablator was used. The first Rotablator got stuck on the wire and we were unable to use that, again we attempted to use it and we did rotablate the lesion maybe in very little and then again taking the Rotablator back into the guide, the wire was pulled and the decision was made to stop the case. There was no hemodynamic instability during the case. The patient otherwise tolerated the procedure well. We will discuss the options with the patient after the case.