bhargavi
Guru
Conclusion
This patient with prior treatment for coronary artery disease status post CABG x4 in 2003 presented with chest pain, acute respiratory distress requiring ventilator support was found to have ST elevation myocardial infarction. Left heart catheterization was recommended.
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After obtaining informed consent, the patient was prepped and draped in sterile fashion. A 6 French sheath was inserted in the right common femoral artery. A 6 French Judkins left and right coronary catheters was used for left and right coronary angiography. Iliofemoral angiography revealed presence of sheath in the common femoral artery. A mynx closure device was used to close the right common femoral artery access site.
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Hemodynamics:
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The left ventricular end-diastolic pressure was 29 mmHg. The aortic pressure was 120/58 mmHg.
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Coronary Angiography:
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Right coronary artery is a small caliber vessel with severe diffuse disease and 100% mid vessel occlusion.
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Left Main coronary artery has diffuse disease.
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Left anterior descending is a medium caliber vessel with proximal to mid diffuse disease and 100% mid vessel chronic total occlusion. Distal competitive flow was noted.
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Left circumflex artery is 100% occluded at the ostium.
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GRAFTS:
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LIMA to LAD is widely patent with disease in the native LAD after the anastomosis.
SVG to RPDA is occluded.
SVG to OM has a patent proximal stent with mild ISR and mild distal disease.
SVG to ramus has 2 focal 90% lesions in the proximal and mid section. There is mild disease noted at the anastomosis.
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Left ventriculogram: Left ventricular cavity was entered using JR4 diagnostic catheter and LVEDP was measured at 29 mmHg.
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The patient was then transferred to the recovery area in stable condition:
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Summary conclusion:
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1. STelevation myocardial infarction
2. Coronary artery disease status post CABG x4 in 2003
3. Chronic kidney disease status post renal transplant
4. uncontrolled hypertension
5. Dyslipidemia
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Recommendation:
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Recommend PCI of SVG to ramus graft in the setting of ST elevation microinfarction.
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6 French JR4 guide was used to engage the SVG to ramus graft. EZ filter wire was advanced into the distal ramus. Filter was deployed in the distal vessel and delivery catheter was withdrawn. Distal lesion was stented using 2.5 x 12 mm resolute integrity stent. Proximal lesion was also direct stented using a 2.5 x 12 mm resolute integrity stent. Both lesions were postdilated using a 2.75 x 8 mm noncompliant balloon under high pressure. 200 mcg of nitroglycerin and 200 mg of Cardene were administered via guide catheter to prevent no reflow. Filter retrieval catheter was inserted and both filter wire were removed. Final angiography revealed TIMI-3 flow into the distal ramus without evidence of perforation or dissection.
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Recommend aspirin and Brilinta for at least 12 months. Patient should follow-up at Temple University Hospital regarding his renal dysfunction.
*
*thanks in advance
I am thinking 93459-xu, c9606- since its stemi or should I do c9604? svg graft to ramus
I am coding for hospital
*
This patient with prior treatment for coronary artery disease status post CABG x4 in 2003 presented with chest pain, acute respiratory distress requiring ventilator support was found to have ST elevation myocardial infarction. Left heart catheterization was recommended.
*
After obtaining informed consent, the patient was prepped and draped in sterile fashion. A 6 French sheath was inserted in the right common femoral artery. A 6 French Judkins left and right coronary catheters was used for left and right coronary angiography. Iliofemoral angiography revealed presence of sheath in the common femoral artery. A mynx closure device was used to close the right common femoral artery access site.
*
Hemodynamics:
*
The left ventricular end-diastolic pressure was 29 mmHg. The aortic pressure was 120/58 mmHg.
*
Coronary Angiography:
*
Right coronary artery is a small caliber vessel with severe diffuse disease and 100% mid vessel occlusion.
*
Left Main coronary artery has diffuse disease.
*
Left anterior descending is a medium caliber vessel with proximal to mid diffuse disease and 100% mid vessel chronic total occlusion. Distal competitive flow was noted.
*
Left circumflex artery is 100% occluded at the ostium.
*
GRAFTS:
*
LIMA to LAD is widely patent with disease in the native LAD after the anastomosis.
SVG to RPDA is occluded.
SVG to OM has a patent proximal stent with mild ISR and mild distal disease.
SVG to ramus has 2 focal 90% lesions in the proximal and mid section. There is mild disease noted at the anastomosis.
*
Left ventriculogram: Left ventricular cavity was entered using JR4 diagnostic catheter and LVEDP was measured at 29 mmHg.
*
The patient was then transferred to the recovery area in stable condition:
*
Summary conclusion:
*
1. STelevation myocardial infarction
2. Coronary artery disease status post CABG x4 in 2003
3. Chronic kidney disease status post renal transplant
4. uncontrolled hypertension
5. Dyslipidemia
*
Recommendation:
*
Recommend PCI of SVG to ramus graft in the setting of ST elevation microinfarction.
*
6 French JR4 guide was used to engage the SVG to ramus graft. EZ filter wire was advanced into the distal ramus. Filter was deployed in the distal vessel and delivery catheter was withdrawn. Distal lesion was stented using 2.5 x 12 mm resolute integrity stent. Proximal lesion was also direct stented using a 2.5 x 12 mm resolute integrity stent. Both lesions were postdilated using a 2.75 x 8 mm noncompliant balloon under high pressure. 200 mcg of nitroglycerin and 200 mg of Cardene were administered via guide catheter to prevent no reflow. Filter retrieval catheter was inserted and both filter wire were removed. Final angiography revealed TIMI-3 flow into the distal ramus without evidence of perforation or dissection.
*
Recommend aspirin and Brilinta for at least 12 months. Patient should follow-up at Temple University Hospital regarding his renal dysfunction.
*
*thanks in advance
I am thinking 93459-xu, c9606- since its stemi or should I do c9604? svg graft to ramus
I am coding for hospital
*