bhargavi
Guru
Pre-procedure Diagnosis
STEMI
Link to Procedure Log
Procedure Log
Post-procedure Diagnosis
STEMI
Indications
STEMI involving left circumflex coronary artery (CMS-HCC) [I21.21 (ICD-10-CM)]
Conclusion
After obtaining informed consent, the patient was prepped and draped in sterile fashion. Approximately 10 mL 2% lidocaine anesthesia was administered to the right groin prior to placement of the arterial sheath. Under fluoroscopic guidance and using modified Seldinger technique, a 6 French arterial sheath was placed without difficulty into the right femoral artery. We then proceeded with left heart catheterization, coronary angiography, selective vein graft angiography, LIMA angiography, and nonselective injection of the right femoral artery using hand injections of Visipaque contrast via 6 French FL4 and FR4 catheters. Findings are as follows:
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The left ventricular pressure was 150/20 mmHg. The aortic pressure was 150/79 mmHg.
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Left Main: The left main is a moderate-sized vessel which bifurcates into left anterior descending and left circumflex branches. There is ostial 70% disease in the left main.
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Left anterior descending: The left anterior descending is 100% occluded at the ostium.
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Left circumflex: Left circumflex is a moderate sized anatomically nondominant vessel which gives rise to 2 major obtuse marginal branches. There is no disease in the proximal left circumflex. The first obtuse marginal branch is 100% occluded proximally. Just beyond the origin of the first obtuse marginal branch in the mid left circumflex, there is a lengthy 75-80% stenosis. This subtends a medium-sized second obtuse marginal branch which has mild luminal irregularities. The appearance of the left circumflex is unchanged compared to the previous angiogram in September 2016.
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Right coronary artery: The right coronary artery is a large anatomically dominant vessel which is rise to the posterior descending and posterior lateral branches. There is ostial 40-50% disease in the right coronary artery which is unchanged from a previous catheterization in September 2016. Ends are visualized in the proximal to late mid segment of the vessel. The stents are all widely patent and free of in-stent restenosis. The posterior descending branch is medium in caliber and has an early mid 80-90% stenosis. The posterior lateral branch is moderate to large in caliber and free of disease.
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Saphenous vein bypass graft to right coronary artery: Known to be occluded from previous catheterization.
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Saphenous vein graft to first obtuse marginal branch: Proximal acute occlusion of this vessel with no collateralization noted.
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LIMA the left anterior descending: Widely patent with excellent runoff to the left anterior descending.
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After identification of acute occlusion of the vein graft to obtuse marginal branch, we elected to proceed with percutaneous intervention. The existing 6 French sheath was maintained in place. Heparin at a dose of 3000 units by intravenous bolus was administered in order to achieve an activated clotting time in excess of 200 seconds. At the end of the procedure, a 600 mg oral Plavix load was administered. The vein graft was then selectively engaged utilizing a 6 French JR4 guide catheter. We then obtained a 300 cm length 0.014 inch balanced middleweight guidewire which was advanced with minimal difficulty through the point of occlusion and into the distal vessel beyond the graft insertion. Follow-up angiography after placement of the coronary guidewire revealed resumption of TIMI grade II-III flow in the vessel with an extensive area of thrombus noted within the vein graft. We then obtained a Pronto V4 catheter and performed a single pass thrombectomy with this catheter. Examination of the Pronto aspirate revealed a large area of red cell thrombus with significant platelet thrombus. Follow-up angiography after withdrawal of the Pronto revealed a significant improvement in thrombus burden with a residual stenosis of 70-80% in the proximal vein graft. There was no evidence of distal embolization. We then performed predilatation of the area of disease utilizing 3.0 x 20 mm emerge balloon up to 12 atm of pressure. Follow-up angiography after balloon angioplasty and administration of 200 mcg of intracoronary nitroglycerin revealed an improvement in the angiographic appearance the vessel. We then proceeded with stenting, placing a single 3.5 x 24 mm Cobra PzF stent in the proximal vessel deployed to 12 atm of pressure. Follow-up angiography revealed a very good angiographic result with a focal area of mild diminishment of stent deployment in the proximal third of the stent. We then performed postdilatation of this area utilizing a 3.5 x 12 mm NC emerge balloon to as high as 18 atm of pressure over 2 overlapping inflations. Follow-up angiography revealed an excellent angiographic result with no significant residual stenosis and no evidence of proximal or distal edge dissection, thrombosis, or spasm. There was TIMI grade III flow throughout the vein graft and into the distal vascular distribution, and the patient's symptoms had improved. We therefore concluded the angioplasty procedure. The coronary guidewire was removed, and final angiography revealed stable to me flows in this vessel. We then concluded the angiographic procedure. The guide catheter was removed.
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Left ventriculogram: Left ventriculography was not performed due to the presence of renal insufficiency.
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Nonselective injection of the right femoral artery revealed acceptable position of the arterial sheath in the common femoral artery above the bifurcation. There was no evidence of angiographic disease at the site of sheath insertion. As such, a 6 French Angio-Seal was placed without difficulty following documentation of an ending activated clotting time of 222 seconds.
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The patient was then transferred to the recovery area in stable condition:
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Impression:
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1. Severe native left coronary disease.
2. Moderate ostial right coronary artery stenosis with widely patent stents and severe disease of small to medium-sized posterior descending branch. The only change in appearance of the right coronary artery was due to worsening of the posterior descending branch stenosis.
3. Acute occlusion of SVG to OM, status post successful recanalization, thrombectomy, angioplasty, and single stent placement.
4. Widely patent LIMA to LAD.
5. Mildly elevated LVEDP.
6. Status post Angio-Seal placed
thank you in advance
should I do 93459-xu, c9606-lc since stemi case or since done thru graft should I do c9604-lc I do hospital coding
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STEMI
Link to Procedure Log
Procedure Log
Post-procedure Diagnosis
STEMI
Indications
STEMI involving left circumflex coronary artery (CMS-HCC) [I21.21 (ICD-10-CM)]
Conclusion
After obtaining informed consent, the patient was prepped and draped in sterile fashion. Approximately 10 mL 2% lidocaine anesthesia was administered to the right groin prior to placement of the arterial sheath. Under fluoroscopic guidance and using modified Seldinger technique, a 6 French arterial sheath was placed without difficulty into the right femoral artery. We then proceeded with left heart catheterization, coronary angiography, selective vein graft angiography, LIMA angiography, and nonselective injection of the right femoral artery using hand injections of Visipaque contrast via 6 French FL4 and FR4 catheters. Findings are as follows:
*
*
The left ventricular pressure was 150/20 mmHg. The aortic pressure was 150/79 mmHg.
*
Left Main: The left main is a moderate-sized vessel which bifurcates into left anterior descending and left circumflex branches. There is ostial 70% disease in the left main.
*
Left anterior descending: The left anterior descending is 100% occluded at the ostium.
*
Left circumflex: Left circumflex is a moderate sized anatomically nondominant vessel which gives rise to 2 major obtuse marginal branches. There is no disease in the proximal left circumflex. The first obtuse marginal branch is 100% occluded proximally. Just beyond the origin of the first obtuse marginal branch in the mid left circumflex, there is a lengthy 75-80% stenosis. This subtends a medium-sized second obtuse marginal branch which has mild luminal irregularities. The appearance of the left circumflex is unchanged compared to the previous angiogram in September 2016.
*
Right coronary artery: The right coronary artery is a large anatomically dominant vessel which is rise to the posterior descending and posterior lateral branches. There is ostial 40-50% disease in the right coronary artery which is unchanged from a previous catheterization in September 2016. Ends are visualized in the proximal to late mid segment of the vessel. The stents are all widely patent and free of in-stent restenosis. The posterior descending branch is medium in caliber and has an early mid 80-90% stenosis. The posterior lateral branch is moderate to large in caliber and free of disease.
*
Saphenous vein bypass graft to right coronary artery: Known to be occluded from previous catheterization.
*
Saphenous vein graft to first obtuse marginal branch: Proximal acute occlusion of this vessel with no collateralization noted.
*
LIMA the left anterior descending: Widely patent with excellent runoff to the left anterior descending.
*
After identification of acute occlusion of the vein graft to obtuse marginal branch, we elected to proceed with percutaneous intervention. The existing 6 French sheath was maintained in place. Heparin at a dose of 3000 units by intravenous bolus was administered in order to achieve an activated clotting time in excess of 200 seconds. At the end of the procedure, a 600 mg oral Plavix load was administered. The vein graft was then selectively engaged utilizing a 6 French JR4 guide catheter. We then obtained a 300 cm length 0.014 inch balanced middleweight guidewire which was advanced with minimal difficulty through the point of occlusion and into the distal vessel beyond the graft insertion. Follow-up angiography after placement of the coronary guidewire revealed resumption of TIMI grade II-III flow in the vessel with an extensive area of thrombus noted within the vein graft. We then obtained a Pronto V4 catheter and performed a single pass thrombectomy with this catheter. Examination of the Pronto aspirate revealed a large area of red cell thrombus with significant platelet thrombus. Follow-up angiography after withdrawal of the Pronto revealed a significant improvement in thrombus burden with a residual stenosis of 70-80% in the proximal vein graft. There was no evidence of distal embolization. We then performed predilatation of the area of disease utilizing 3.0 x 20 mm emerge balloon up to 12 atm of pressure. Follow-up angiography after balloon angioplasty and administration of 200 mcg of intracoronary nitroglycerin revealed an improvement in the angiographic appearance the vessel. We then proceeded with stenting, placing a single 3.5 x 24 mm Cobra PzF stent in the proximal vessel deployed to 12 atm of pressure. Follow-up angiography revealed a very good angiographic result with a focal area of mild diminishment of stent deployment in the proximal third of the stent. We then performed postdilatation of this area utilizing a 3.5 x 12 mm NC emerge balloon to as high as 18 atm of pressure over 2 overlapping inflations. Follow-up angiography revealed an excellent angiographic result with no significant residual stenosis and no evidence of proximal or distal edge dissection, thrombosis, or spasm. There was TIMI grade III flow throughout the vein graft and into the distal vascular distribution, and the patient's symptoms had improved. We therefore concluded the angioplasty procedure. The coronary guidewire was removed, and final angiography revealed stable to me flows in this vessel. We then concluded the angiographic procedure. The guide catheter was removed.
*
Left ventriculogram: Left ventriculography was not performed due to the presence of renal insufficiency.
*
Nonselective injection of the right femoral artery revealed acceptable position of the arterial sheath in the common femoral artery above the bifurcation. There was no evidence of angiographic disease at the site of sheath insertion. As such, a 6 French Angio-Seal was placed without difficulty following documentation of an ending activated clotting time of 222 seconds.
*
The patient was then transferred to the recovery area in stable condition:
*
Impression:
*
1. Severe native left coronary disease.
2. Moderate ostial right coronary artery stenosis with widely patent stents and severe disease of small to medium-sized posterior descending branch. The only change in appearance of the right coronary artery was due to worsening of the posterior descending branch stenosis.
3. Acute occlusion of SVG to OM, status post successful recanalization, thrombectomy, angioplasty, and single stent placement.
4. Widely patent LIMA to LAD.
5. Mildly elevated LVEDP.
6. Status post Angio-Seal placed
thank you in advance
should I do 93459-xu, c9606-lc since stemi case or since done thru graft should I do c9604-lc I do hospital coding
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