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Unsuccessful attempt at stenting of the left carotid artery

  1. #1
    Location
    Jacksonville Florida
    Posts
    126
    Cool Unsuccessful attempt at stenting of the left carotid artery
    Medical Coding Books
    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.

  2. #2
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by jlb102780 View Post
    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.
    I could make a case for 37215-53 but would instead just code what was actually performed, another angiography. This is because the stent was never unpacked or attempted to be placed.

    36217/75676/75665 (left internal carotid is a third order vessel when a bovine arch is present).

    HTH
    Danny L. Peoples
    CIRCC,CPC

  3. #3
    Location
    Jacksonville Florida
    Posts
    126
    Default
    Thanks so much for your help Danny
    Jammie Barsamian, CPC, CCC, CEMC, CCS-P, CPMA

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