Selective Right and Left Carotid Angio, Subclavian Artery & Left Internal Mammary Artery Graft Angiography and PTA and Stenting of Left Subclavian

mcauffman86

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Saint Joseph, MI
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I am really confused on what cath codes to use for this case. Any advice would be greatly appreciated!

Procedure performed: Right and left carotid as well as subclavian artery angiography, left subclavian artery PTA and stenting, selective angiography of the left internal mammary artery graft

Indication: Subclavian artery stenosis with subclavian steel syndrome and left arm claudication

Procedure performed:
1. Fluoroscopy of the upper part of the chest
2. Placement of the sheath in right common femoral artery with the help of ultrasound and micropuncture needle just below the stent and external iliac artery and proximal common femoral artery
3. Selective angiography of the right innominate artery, subclavian artery and bovine carotid artery right-to-left
4. Selective angiography of the left subclavian artery
5. Selective angiography of the left internal mammary artery graft
6. Stenting of the proximal left subclavian artery


Procedure note:
Patient was brought to cath lab draped and prepped in crescendo fashion and under the ultrasound guidance a 6 French sheath was placed in the right common femoral artery. With the JB2 diagnostic catheter selective cannulation of the right innominate artery and then left subclavian artery was performed. After the subclavian artery angiography the pressure gradient was measured across the discrete proximal lesion. That was done at the end of diagnostic catheter. After that with the wire in place a 7 French bright-tip 90 cm catheter was seated the origin of left supraventricular artery. Stenting was performed.

Fluoroscopy and Cine interpretation:

Fluoroscopy shows calcification of the aortic arch is allergic to her aortic bulb with calcification of the proximal subclavian arteries were noted

Right innominate artery: Is patent no stenosis

Right subclavian artery is completely occluded

Right common carotid artery is patent with no stenosis

Left common carotid artery arises bovine origin with no stenosis

Left subclavian artery is Significant plaque irregularity in the ostial and proximal segment. Also the proximal segment shows a discrete stenosis of 70% with 25 mm pressure gradient. The lesion to the origin of the vertebral and left internal mammary artery graft. Further down after the origin of internal mammary artery and vertebral artery is a tubular stenosis of 20% is noted with no pressure gradient

Left internal mammary artery is patent and both proximal and distal attachment with no stenosis is filling of LAD antegradely.

Stenting of left subclavian artery:
Patient was given 4000 units of intravenous heparin. With the wire in place and 9x19 mm Omnilink stent was prepped passed over the wire seated at the area of lesion in proximal circumflex artery not covering the origin of internal mammary to the vertebral artery was deployed at 10 atmospheric pressure. That opened up the area very well with no residual lesion and no pressure gradient.

Cine interpretation:
Pre-PTCA proximal left subclavian artery stenosis of 70% with pressure gradient of 20 mmHg post-stenting rest of her stenosis of 0% with no pressure gradient

Final diagnosis:
1. Significant stenosis of proximal left subclavian artery with successful stenting
2. Patent left internal mammary artery graft with normalization
3. Totally occluded right subclavian artery which is chronic
4. Bovine origin of the left common carotid artery

Recommendation:
Patient started on dual antiplatelet therapy. Rest of her medications to continue as before. Blood pressure negative venous worker.
 

Jim Pawloski

True Blue
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Ann Arbor
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I included those vessels with Carotid, extracrainal, unilateral with selective innominate or CCA position. RT Common carotid was reported. Can't code the subclavian because it's occluded.
HTH,
Jim
 
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