Thoracic procedure


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Are my codes correct or am I missing something?


1. Ultrasound guided left radial artery access
2. Ultrasound guided right common femoral artery access
3. Left subclavian angiogram, atherectomy of subclavian thrombus/occlusion, angioplasty andstenting
4. Laser fenestration into thoracic endograft
5. Arch angiography
6. Abdominal aortic angiography
7. Closure of right common femoral artery with 6F Angioseal
8. Closure of left radial artery with trans-radial band
46M with severe subclavian steal syndromecausing multiple drop spells secondary to advertent subclavian artery coverage followingrepair of type A Ao dissection

Operative Description:
The right common femoral artery was accessed under ultrasound guidance using a 5Fmicropuncture kit; over an 035 wire, a 5F sheath was placed. This was used for arterialblood pressure monitoring as well as completion angiography.
Left radial arterial access was then obtained under ultrasound guidance using 4Fmicropuncture kit and the Seldinger technique. A
F slender sheath was placed over aguidewire. The radial artery was noted to be spasmed and diseased. A cocktail of 2,000units of heparin, 200 micrograms of verapamil, and 200 micrograms of nitroglycerin wereadministered through the left radial artery.
The sheath was up-sized to a 7F 65 cm Destination sheath, and using an 035 Glidewire, an attempt was made to recanalize the subclavian artery. It was noted that the thrombus was very well organized and dense.
The system was downsized to an 018, and using a V18 wire as well as a 2.0 Spectraneticslaser, the thrombus/proximal left subclavian artery was atherectomized and angioplastiedto 3 mm. The laser was then placed on top of the existing endograft, and the laser wasengaged to create an arteriotomy within the graft. Using an 018 Supracore wire, the graftwas selected, and the graftotomy was dilated first to 3 mm, then 6 mm using 018 PacificPlus balloons.
Confirmation of location was performed with a pigtail catheter and angiography within theproximal descending thoracic aorta.
The wire was then exchanged for an 035 Bentson. Over this wire, a 8x39mm VBX wasdelivered and deployed with about 2 mm into the aortic endograft. Selective subclavianangiography demonstrated excellent wall deposition and antegrade flow to the left arm andleft vertebral artery. A pigtail catheter was then used to perform an arch angiogram, whichdemonstrated a sound repair of the ascending aorta with bifurcated grafts to the bilateral
carotid arteries. The left subclavian artery filled antegrade as well as the left vertebralartery. Flow to the left arm is brisk. At this point, the junction between the graft and thesubclavian stent was post-dilated to 9 mm to ensure good seal. Completion angiographyagain confirmed this, with no evidence of endoleak or extravasation.

Abdominal aortic angiography also confirmed patent celiac, superior mesenteric, andbilateral renal arteries without evidence of disease, dissection, or malperfusion.
Anesthesia was reversed, and the patient was taken to recovery in stable condition.