jlb102780
Guru
Here's a copy of the report, I know its pretty long. But very detailed. Any help on coding this would be great. I've not come across an Unsuccessful procedure before. Thanks 
Jammie Mack, CPC
CARDIOLOGY SERVICES REPORT
DATE OF TEST: 10/08/2009
NAME OF PROCEDURE
Left carotid stent.
HISTORY
The patient is a very pleasant unfortunate 88-year-old female who has had
recurrent symptoms of TIA. She has a carotid angiogram performed at Memorial
Medical Center a couple of months ago and was found to have an ulcerated 60
to 70% plaquing in her left internal carotid artery. She was set up to have
a carotid stent placed over there in a couple of weeks. The patient has
multiple medical problems including severe coronary artery disease as well as
reduced left ventricular systolic function. She is admitted over here to
Baptist Medical Center. Dr. Schimmel, her regular cardiologist consulted me
and asked me to try to place a carotid stent. I reviewed her films carefully
from her angiogram at Memorial Medical Center a couple of months ago. She
was noted to have a bovine aortic arch with relatively small carotid arteries.
The patient also has significant renal insufficiency. She was started on
Mucomyst and was given intravenous fluids. She has been followed by the
renal service as well.
PROCEDURE
The patient was brought to the cardiac cath lab in relatively stable
condition. She was placed on the cath lab stretcher. She was prepped and
draped in the usual sterile fashion. She was having some complaints of right
and left hip pain from arthritis. Laying on the cardiac cath lab table was
very uncomfortable for her. We decided to sedate her slightly. She was
given 50 micrograms of intravenous fentanyl and 25 mg of intravenous
Benadryl. This worked very nicely to sedate her for the procedure. She was
very stable. She was arousable during the procedure, however.
The right groin area was prepped and draped in the usual sterile fashion.
Using 1% Xylocaine, the right femoral area was anesthetized. Using a Cook
needle, the right femoral artery was entered without difficulty and a 6
French sheath was inserted via Seldinger technique. The sheath was aspirated
and flushed. A 4 French glide catheter was then carefully advanced over a J
wire up into the patient's ascending aorta. We were unable to manipulate the
4 French angled Glide catheter into the patient's left carotid artery. We
subsequently switched out over a J wire for a 4 French HN5 diagnostic
catheter. This diagnostic catheter was successfully manipulated into the
proximal aspect of the patient's left common carotid artery. An angled Glide
wire was manipulated up into the patient's left internal carotid artery. We
then carefully switched out for a 4 French angled Glide catheter. This Glide
catheter was advanced up over the Glide wire up into the patient's left
common carotid artery. The Glide wire was then removed. We performed a
cineangiogram utilizing digital subtraction angiography in LAO projection and
documented the patient did have a 70% or so lesion in her left internal
carotid artery. Her left common carotid artery and her left internal carotid
artery were relatively small vessels. The left external carotid artery was a
very small vessel.
I then was able to manipulate the Glide wire up into the patient's left
external carotid artery. We placed a Glide catheter up into the patient's
left external carotid artery. We then removed the Glide wire. We switched
out for a Supra Core wire which is a 0.035 inch wire. The tip of the wire
was very floppy but the rest of the wire was very stiff in order to deliver a
sheath. Unfortunately, we tried to place this exchange wire up into the
patient's left carotid artery, a Multipurpose catheter would not support
this. The Multipurpose catheter prolapsed down into the aorta.
We removed the Multipurpose catheter with a conventional J wire. The patient
had been given 5,000 units of intravenous heparin once we successfully
cannulated the left carotid artery with the HN5 catheter. We placed the 4
French HN5 catheter back into the patient's left carotid artery. I again
manipulated the angled Glide wire up into the patient's left internal carotid
artery. I then switched out carefully for a 5 French vertebral catheter.
This catheter was manipulated over the Glide wire up into the patient's left
common carotid artery. I then carefully was able to successfully advance the
0.035 inch Supra Core exchange wire up into the distal aspect of the
patient's left common carotid artery. My plan was to just try to get a
sheath to go into the proximal aspect of the left common carotid artery. We
removed the vertebral catheter. We then removed the short sheath. We
attempted to bring up a 6 French Cook shuttle sheath as this is a standard
sheath used for carotid stenting. Unfortunately this sheath would not take
the turn and enter the patient's left common carotid artery. The patient
does have a bovine arch with left common carotid artery arising directly off
of the brachiocephalic artery. The Supra Core wire prolapsed down to the
aorta during this time. I then switched back out over a conventional J wire
for a conventional short 6 French sheath in the right femoral artery.
I reviewed the patient's situation carefully. It was very obvious that we
would not be able to get a 6 French sheath up to negotiate her proximal
aspect of her left common carotid artery due to the fact that she has a
bovine aortic arch. The other option would have been to try with an 8 French
sheath and use a guiding catheter. I felt that the patient had a very small
left common carotid artery as well as a very small left internal carotid
artery. I did not feel that utilizing an 8 French guiding catheter was a
wise decision. The procedure was therefore terminated.
The patient was very stable at the conclusion of the procedure. An ACT was
obtained and was noted to be 215 seconds. Her sheaths will be removed
eventually when her ACT comes down to a target level. She was very arousable
at the conclusion of the case and there was no change in her neurologic
status.
It should also be noted that since we performed only one cineangiogram with
contrast, the patient received a total of only 10 mL of dye for the procedure.
CONCLUSION
Unsuccessful attempt at stenting of the left carotid artery. We were unable
to successfully manipulate a 6 French shuttle sheath into the left common
carotid artery over a stiff wire despite the couple attempts to do so. Since
the patient has a very small left common carotid artery, I felt that trying
to perform the procedure with an 8 French guiding catheter would be
potentially very dangerous. This was therefore not attempted.
Jammie Mack, CPC
CARDIOLOGY SERVICES REPORT
DATE OF TEST: 10/08/2009
NAME OF PROCEDURE
Left carotid stent.
HISTORY
The patient is a very pleasant unfortunate 88-year-old female who has had
recurrent symptoms of TIA. She has a carotid angiogram performed at Memorial
Medical Center a couple of months ago and was found to have an ulcerated 60
to 70% plaquing in her left internal carotid artery. She was set up to have
a carotid stent placed over there in a couple of weeks. The patient has
multiple medical problems including severe coronary artery disease as well as
reduced left ventricular systolic function. She is admitted over here to
Baptist Medical Center. Dr. Schimmel, her regular cardiologist consulted me
and asked me to try to place a carotid stent. I reviewed her films carefully
from her angiogram at Memorial Medical Center a couple of months ago. She
was noted to have a bovine aortic arch with relatively small carotid arteries.
The patient also has significant renal insufficiency. She was started on
Mucomyst and was given intravenous fluids. She has been followed by the
renal service as well.
PROCEDURE
The patient was brought to the cardiac cath lab in relatively stable
condition. She was placed on the cath lab stretcher. She was prepped and
draped in the usual sterile fashion. She was having some complaints of right
and left hip pain from arthritis. Laying on the cardiac cath lab table was
very uncomfortable for her. We decided to sedate her slightly. She was
given 50 micrograms of intravenous fentanyl and 25 mg of intravenous
Benadryl. This worked very nicely to sedate her for the procedure. She was
very stable. She was arousable during the procedure, however.
The right groin area was prepped and draped in the usual sterile fashion.
Using 1% Xylocaine, the right femoral area was anesthetized. Using a Cook
needle, the right femoral artery was entered without difficulty and a 6
French sheath was inserted via Seldinger technique. The sheath was aspirated
and flushed. A 4 French glide catheter was then carefully advanced over a J
wire up into the patient's ascending aorta. We were unable to manipulate the
4 French angled Glide catheter into the patient's left carotid artery. We
subsequently switched out over a J wire for a 4 French HN5 diagnostic
catheter. This diagnostic catheter was successfully manipulated into the
proximal aspect of the patient's left common carotid artery. An angled Glide
wire was manipulated up into the patient's left internal carotid artery. We
then carefully switched out for a 4 French angled Glide catheter. This Glide
catheter was advanced up over the Glide wire up into the patient's left
common carotid artery. The Glide wire was then removed. We performed a
cineangiogram utilizing digital subtraction angiography in LAO projection and
documented the patient did have a 70% or so lesion in her left internal
carotid artery. Her left common carotid artery and her left internal carotid
artery were relatively small vessels. The left external carotid artery was a
very small vessel.
I then was able to manipulate the Glide wire up into the patient's left
external carotid artery. We placed a Glide catheter up into the patient's
left external carotid artery. We then removed the Glide wire. We switched
out for a Supra Core wire which is a 0.035 inch wire. The tip of the wire
was very floppy but the rest of the wire was very stiff in order to deliver a
sheath. Unfortunately, we tried to place this exchange wire up into the
patient's left carotid artery, a Multipurpose catheter would not support
this. The Multipurpose catheter prolapsed down into the aorta.
We removed the Multipurpose catheter with a conventional J wire. The patient
had been given 5,000 units of intravenous heparin once we successfully
cannulated the left carotid artery with the HN5 catheter. We placed the 4
French HN5 catheter back into the patient's left carotid artery. I again
manipulated the angled Glide wire up into the patient's left internal carotid
artery. I then switched out carefully for a 5 French vertebral catheter.
This catheter was manipulated over the Glide wire up into the patient's left
common carotid artery. I then carefully was able to successfully advance the
0.035 inch Supra Core exchange wire up into the distal aspect of the
patient's left common carotid artery. My plan was to just try to get a
sheath to go into the proximal aspect of the left common carotid artery. We
removed the vertebral catheter. We then removed the short sheath. We
attempted to bring up a 6 French Cook shuttle sheath as this is a standard
sheath used for carotid stenting. Unfortunately this sheath would not take
the turn and enter the patient's left common carotid artery. The patient
does have a bovine arch with left common carotid artery arising directly off
of the brachiocephalic artery. The Supra Core wire prolapsed down to the
aorta during this time. I then switched back out over a conventional J wire
for a conventional short 6 French sheath in the right femoral artery.
I reviewed the patient's situation carefully. It was very obvious that we
would not be able to get a 6 French sheath up to negotiate her proximal
aspect of her left common carotid artery due to the fact that she has a
bovine aortic arch. The other option would have been to try with an 8 French
sheath and use a guiding catheter. I felt that the patient had a very small
left common carotid artery as well as a very small left internal carotid
artery. I did not feel that utilizing an 8 French guiding catheter was a
wise decision. The procedure was therefore terminated.
The patient was very stable at the conclusion of the procedure. An ACT was
obtained and was noted to be 215 seconds. Her sheaths will be removed
eventually when her ACT comes down to a target level. She was very arousable
at the conclusion of the case and there was no change in her neurologic
status.
It should also be noted that since we performed only one cineangiogram with
contrast, the patient received a total of only 10 mL of dye for the procedure.
CONCLUSION
Unsuccessful attempt at stenting of the left carotid artery. We were unable
to successfully manipulate a 6 French shuttle sheath into the left common
carotid artery over a stiff wire despite the couple attempts to do so. Since
the patient has a very small left common carotid artery, I felt that trying
to perform the procedure with an 8 French guiding catheter would be
potentially very dangerous. This was therefore not attempted.