Upper Extremity Angio

mcauffman86

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Saint Joseph, MI
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Can someone please help me with the cath placement coding of this case? I am so confused because it looks like there were two different access sites, right common fem and right radial??

Procedure Ordered:
Procedure(s):
Upper Extremity Angio Poss PTA

Indications:
Symptomatic innominate/brachiocephalic artery stenosis.

Procedure Performed:
Aortic arch angiography
Selective right carotid angiography.

Pre-Procedure Diagnosis:
I77.1
Stenosis of brachiocephalic artery (HCC)
Mixed dyslipidemia
S/P mitral valve repair
Cardiomyopathy, unspecified type (HCC)
Dyspnea on exertion
Right arm claudication

Post-Procedure Diagnosis:
Heavily calcified focal proximal stenosis 90% proximal innominate artery, 50% stenosis proximal right subclavian artery.

Moderate Sedation:
Moderate sedation was administered using IV Versed and Fentanyl. Patient received continuous EKG, hemodynamic and oximetry monitoring with physician being present for the entire time. Total moderate sedation duration = 61 min.

Estimated Blood Loss:
Minimal

Complications:
No Complications were logged

Procedure Technique:
The risks, benefits, alternatives were explained at length with the patient written informed consent was obtained. The patient is brought to the cardiac catheterization laboratory in the postabsorptive state. The right radial artery and right groin were prepped and draped in usual sterile fashion conscious sedation was administered. The right radial pulse was faint and weak and difficult to palpate. Ultrasound was utilized for access. 1% lidocaine was used for local infiltration and a 6 French slender Terumo sheath was placed utilizing the true Salinger technique. Using ultrasound guidance for the right common femoral artery 1% lidocaine was used for local infiltration and 18 x 7 needle was used to access the right common femoral artery a J-wire was advanced without difficulty and a 6 French short sheath was placed utilizing the modified Salinger technique. A 5 French pigtail catheter was advanced to the ascending portion of the aortic arch and in the 30° LAO projection digital subtraction angiography was performed. A JB 25 French diagnostic catheter was advanced to the origin of the innominate artery and digital subtraction angiography in the AP and arterial projections were performed. A stiff angled Glidewire was attempted to cross the stenosis of the innominate artery which was a heavily calcified 90% stenosis, unsuccessful. The stiff angled Glidewire was then placed through the radial artery and able to easily cross the innominate stenosis and placed in the aortic arch. The patient developed right groin pain and discomfort and it was discovered that she had a large hematoma developing at the right groin site. At this point the stiff angled Glidewire was removed as well as the JB 2 diagnostic catheter. Due to the large hematoma in the right groin, I elected to abort further peripheral vascular intervention. Selective angiography of the right common femoral artery in the RAO projection was performed arteriotomy site midportion of the vessel no extravasation of contrast, dissection or perforation noted. Manual pressure was applied to the hematoma and the patient was transported to the holding area hemodynamically stable.


Angiographic Data:
Aortic arch angiography: Type III aortic arch with separate ostium for the innominate artery, left carotid artery, left subclavian. The innominate artery demonstrates a heavily calcified focal stenosis involving the proximal portion of the vessel of 90% there is a secondary stenosis involving the proximal portion of the right subclavian artery heavily calcified of 50%, the right vertebral artery was not visualized although the right internal mammary artery was opacified. The right common carotid artery is widely patent although there is heavy circumferential calcification and involving the right carotid bulb which is patent. The mid and distal portion of the right subclavian artery appear angiographically normal as well as the right axillary artery. There is Calcification involving the origin of the left carotid artery with resulting stenosis of 20-30% the mid and distal portions of the left common carotid artery appear angiographically normal. The left subclavian artery also demonstrates mild disease at the origin of 20% a large vertebral artery emanated's from the subclavian artery subclavian artery demonstrates minimal luminal irregularities and no focal disease.

Selective angiography right carotid artery: 90% heavily calcified proximal stenosis innominate artery 50% stenosis proximal subclavian artery right heavily calcified right common carotid artery angiographically normal bulb demonstrating heavy extra luminal calcification without resultant focal stenosis. Right vertebral artery not opacified.

Final Diagnosis:
1. Type III aortic arch.
2. 90% calcified focal stenosis involving the proximal innominate artery
3. 50% eccentric stenosis heavily calcified right subclavian artery.
 

such78

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"The right radial artery and right groin were prepped and draped in usual sterile fashion conscious sedation was administered." They made 2 different accesses. 36140 is for the right common artery, and the catheter is not documented go beyond/further, so code it as non-selected.
 

mcauffman86

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Saint Joseph, MI
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"The right radial artery and right groin were prepped and draped in usual sterile fashion conscious sedation was administered." They made 2 different accesses. 36140 is for the right common artery, and the catheter is not documented go beyond/further, so code it as non-selected.
Ah yes, thank you for the explanation!
 
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