Help coding! R & L Cath with Peripheral procedure
Hi everyone! Here's another really long report that I'm stuck on. Any help coding this would be so wonderful
NAME OF TEST:
1. Left and right heart cardiac catheterization.
2. Coronary angiography.
3. Left ventriculography.
4. Abdominal aortogram.
5. PTA of the right external iliac artery.
6. Implantation of a 8 mm (16 mm long) Absolute self expanding peripheral
stent in the very distal aspect of the right common iliac artery
extending down almost the entire length of the right external iliac
The patient is a very unfortunate, 41-year-old female who has end stage renal
disease. She developed bacterial endocarditis in the past year or so up in
Virginia. She was treated for this. She had severe mitral regurgitation.
She was treated with a prolonged course apparently of antibiotics and was
treated medically. She has begun to experience symptoms of dyspnea. She had
an echocardiogram with Doppler study and was found to have severe mitral
regurgitation. There was concerns about a catheter infection as well. The
patient was discharged home from Baptist Medical Center and came back with
acute pulmonary edema. After careful discussion of the various options, she
was referred for a right and left heart cardiac catheterization.
The patient was brought to the cardiac catheterization laboratory in very
stable condition. Both groins were carefully prepped and draped in the usual
sterile fashion. She was found to have very poor pulses in both groins. We
elected to use the right side. The patient was anesthetized using 1%
Xylocaine. She was also given some intravenous sedation. Please see the
accompanying nursing data sheet for full details regarding her sedation. I
was able to easily cannulate the right femoral vein without significant
difficulty. A 7 French venous sheath was then inserted in the right femoral
vein. We then had a great deal of difficulty trying to cannulate the right
femoral artery. The pulse was very poor. I decided to proceed on with the
right heart cardiac catheterization. We advanced the 7 French Swan-Ganz
catheter up over a J wire and manipulated the catheter out into the patient's
left pulmonary artery. A pulmonary pressure was obtained as well as a
pulmonary capillary wedge pressure. The catheter was then pulled back into
the patient's right ventricle after obtaining an arterial saturation
measurement within the left pulmonary artery. A right ventricular pressure
was then obtained. A right atrial pressure was obtained as well. The
pigtail catheter was then removed.
After some more difficulty, I was able to successfully cannulate the
patient's right femoral artery. A J tip wire was manipulated after some mild
difficulty up the patient's right femoral artery subsequently into the right
iliac artery up into the aorta. The wire was clearly in the aorta distally.
I advanced a 5 French sheath carefully up the patient's right femoral artery
over the J wire. We then advanced a 5 French 4 left Judkins coronary
diagnostic catheter. All subsequent wire exchanges were performed over an
exchange wire. Diagnostic coronary angiography was then performed utilizing
a 5 French 4 left Judkins and a 5 French 4 right Judkins coronary diagnostic
catheter in order to inject the left and right coronary arteries,
respectively. A left ventriculogram was then performed in the 30 degree RAO
projection utilizing a 6 French angled pigtail catheter. This angled pigtail
catheter was then pulled back across the aortic valve. It should be noted
that upon obtaining the arterial access, we did measure the arterial
saturation measurement in the patient's aorta. She was noted to have room
air oxygen saturation of 90%.
The patient was noted to have severe mitral regurgitation as expected. Left
ventricular systolic function, however, was somewhat decreased and the
ejection fraction was only approximately 50%. In addition, we obtained a net
for cardiac output by the FICK method of 2.7 liters per minute. I felt that
the patient might need to have an intraaortic balloon pump placed in order to
get through cardiac surgery eventually. I felt that it would be helpful to
perform an abdominal aortogram in order to assess the patient's abdominal
aorta as well as her iliac arteries. She did have stents in both iliac
arteries. These were self expanding stents that were easily visualized under
I initially performed an abdominal aortogram with the pigtail catheter being
placed at the level of the first lumbar vertebrae. I was able to visualize
the patient's abdominal aorta. She did have some narrowing in the abdominal
aorta but the vessel was patent.
We then pulled the pigtail catheter down until it was located just above the
aortic bifurcation. A second abdominal aortogram was performed to look at
the iliac and femoral arteries. On the left side, the patient was noted to
have a stent in her left iliac artery that was widely patent. She did have
some narrowing in her left external iliac artery. This vessel was patent.
Her right external iliac artery, however, with the catheter passing across it
appeared to be essentially totally occluded after the takeoff of the right
internal iliac artery. I removed the catheter and pulled the sheath back
slightly with the J wire up well into the patient's abdominal aorta. The
injection was performed through the sheath and the patient was noted to have
essentially a subtotally occluded right external iliac artery almost along
its entire length.
At this point, I felt that we needed to perform some type of catheter based
intervention to try to obtain patency of the right external iliac artery. I
felt that if I did not do this that when I pulled the J wire back the patient
could develop an ischemic right leg. I felt this was essentially an
emergency. In addition, I also felt that the patient may need to have an
intraaortic balloon pump and achieve an access for this. I therefore
performed an additional cineangiogram through the sheath in the 30 degree LAO
projection. This laid out the takeoff of the right external iliac artery
very nicely. I then selected a 5 mm peripheral balloon catheter, the balloon
being 40 mm in length. A total of three balloon inflations were made with
this catheter. We then deflated the balloon catheter and removed it.
Subsequent cineangiograms revealed a significant improvement at the PTCA
site. I then selected a 6 mm peripheral balloon catheter with the balloon
being 40 mm in length. Three balloon inflations were made with this
catheter. We then deflated the balloon catheter and removed it. Subsequent
cineangiograms revealed a much more widely patent right external iliac artery
now. There was one area, however, at the takeoff of the right external iliac
artery where the artery was still very tightly narrowed. I felt that we
needed to place a self expanding stent and would have to place the most
distal part of the stent up into the distal aspect of the patient's right
common iliac artery. I therefore selected an 8 mm Absolute self expanding
stent with the stent being 60 mm in length. I brought this stent down to
what I felt was then most optimal position. When we had it in this position,
we removed the deployment sheath. The stent appeared to expand very nicely.
I then postdilated the stent with a 6 mm Agile Track balloon catheter we
utilized earlier. Two balloon inflations were made within the stent.
We then deflated the balloon catheter and removed it. The right iliac artery
and right external iliac artery were now widely patent. There was excellent
flow up the vessel. We could see runoff into the contralateral iliac artery
as well. In addition, the patient now had a normal pressure wave form
tracing at the sheath insertion site in the right femoral artery.
The patient tolerated the procedure quite well. There were no complications.
She was taken to the cardiac catheterization laboratory holding area in order
to have her sheaths pulled.
1. Mean right atrial pressure is 17.
2. Right ventricle pressure is 65/13.
3. Mean pulmonary artery pressure is 65/27 with a mean of 42.
4. Mean pulmonary artery capillary wedge pressure is 29 with a V wave
equal to 50.
5. Left ventricular pressure is 87/21.
6. Aortic pressure 94/77 with a mean of 85.
7. Oxygen saturation: Aorta 90%, pulmonary artery 42%, cardiac output
FICK 2.7 liters per minute.
FEMORAL ARTERY PRESSURES
1. Prior to stent placement the right femoral artery is 59/54 with a mean
2. After stent placement right femoral artery 106/72 with a mean of 84.
1. The left main coronary artery is normal.
2. The left anterior descending coronary artery is normal.
3. The left circumflex coronary artery is normal.
4. The right coronary artery is a large and dominant vessel which is
5. Left ventriculogram reveals a dilated left ventricle. Left ventricular
systolic function is somewhat reduced and the overall left ventricular
ejection fraction was estimated to be approximately 50%. There was
severe mitral regurgitation detected. The left atrium is markedly
6. Abdominal aortogram reveals an unremarkable abdominal aorta. The right
common iliac artery has a stent present which is patent. The right
external iliac artery is subtotally occluded at its takeoff. The left
common iliac artery has stents present that are widely patent. There
is some mild narrowing noted within the stent. The left external
iliac artery has a 40 to 50% obstructive narrowing noted within it.
7. After successful PTA and subsequent implantation of an 8 mm (16 mm
long) Absolute self expanding stent into the distal right common iliac
artery extending along the entire length of the right external iliac
artery, the subtotally occluded right external iliac artery
preintervention was reduced to no residual narrowing postintervention.
There is excellent flow in the distal vessel. There is no dissection.
1. Marked pulmonary hypertension secondary to elevated pulmonary capillary
wedge pressure secondary to severe mitral regurgitation.
2. Reduced cardiac output secondary to severe mitral regurgitation.
3. Dilated left ventricle with reduced left ventricular systolic function.
4. Markedly dilated left atrium.
5. Angiographically normal coronary arteries.
6. Abdominal aortogram revealing widely patent stents in both common iliac
arteries bilaterally with the right external iliac artery being
7. Successful PTA with subsequent implantation of an 8 mm (16 mm long)
Absolute self expanding peripheral stent in the very distal aspect of
the right common iliac artery extending almost the entire length of
the right external iliac artery. The subtotally occluded right
external iliac artery preintervention was reduced to no residual
narrowing postintervention. There was excellent flow in the distal
vessel. There was no evidence of dissection.
Jammie Barsamian, CPC, CCC, CEMC, CCS-P, CPMA