Left Heart Cath with 3 Stent Locations
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PREOPERATIVE DIAGNOSIS: Unstable angina, severe.
1. Multivessel coronary artery disease.
2. Multivessel intervention.
1. Left heart catheterization.
2. Coronary angiography.
3. Intraaortic balloon pump.
4. Percutaneous coronary intervention of:
a. Circumflex coronary artery.
b. Left anterior descending artery.
c. Right coronary artery.
PROCEDURE: The patient was prepped and draped in the usual fashion and brought
to the catheterization lab having been premedicated with Xanax and Benadryl.
Using 2% local Xylocaine, the right femoral region was anesthetized. Using the
single-wall technique, the right femoral artery was entered. An introducer
sheath was placed, through which a 4 left Judkins was advanced to the ostium of
the left coronary artery. Several hand injections visualized the artery in
various projections. This catheter was removed and placed with a Williams
right catheter, which was advanced to the ostium of the right coronary artery.
Several hand injections visualized the artery in various projections.
At this juncture, the patient actually became quite unstable and had severe
chest discomfort, 8/10 or 10/10. She was hypotensive with blood pressure 80-90
and tachycardia Because of this, it was elected to place an intraaortic
The left femoral region was anesthetized. Using the single-wall technique, the
left femoral artery was entered. An introducer sheath was placed, through
which an intraaortic balloon pump was brought just below the left subclavian,
and this was pumped at 1:1 with good expansion of the balloon. At this
juncture, the patient was placed on IV nitroglycerin at 30 meg and was given IV
Lopressor 5 mg q.5 minutes x3. The patient began to stabilize with this with
Keeping in mind that the patient was on Plavix and quite unstable, it was
elected to try to stabilize this situation as it would be some time before she
would be able to undergo surgery.
At this point, an XB guide was advanced to the ostium of the left coronary
artery. A S'port wire was prepared and a 3-0 balloon. The wire was advanced
down the circumflex, which was quite tortuous and into the distal vessel. The
balloon was advanced over the wire to the point of the lesion and inflated.
This was then removed, and a 3.5 x 24 Promus Element stent was fully inflated
up to 14 atmospheres. Angiograms post showed a markedly improved artery with
no significant residual.
At this juncture, attention was turned toward a high-grade lesion in the I.AD.
The same guide was used. The S'port wire was advanced down the LAD into the
distal vessel. A 2.0 balloon was brought to the point of the lesion and
expanded, and then a 3.0 x 16-mm Promus Element stent was placed across the
lesion and fully inflated. There was still some residual in-stent narrowing,
and therefore a 3.25 balloon was brought in-stent and fully inflated up to 16
atmospheres. Angiograms post showed a markedly improved artery with no
At this juncture, attention was turned toward the right coronary artery. A 4
right Judkins guide was advanced to the ostium of the right coronary artery. A
S'Port wire was placed down the artery, and then a 3.0 x 16 Promus Element
stent was placed across the lesion and fully inflated up to 16 atmospheres.
This was post dilated with a 3.5 x 8 balloon up to 16 atmospheres. Angiograms
post showed a markedly improved artery.
Prior to the procedure, the patient was also given 1 mg of Versed for conscious
The patient tolerated the procedure well. There were no complications. The
right femoral sheath was removed, and Angio-Seal was placed. The intraaortic
balloon pump was sewn in place, and the patient returned then to the intensive
care unit in stable condition.
1. Severe coronary artery disease: Left main was within normal limits. The
LAD showed a proximal 90-plus-percent lesion. There was a small diagonal
with a high-grade lesion. The circumflex showed a 90-plus-percent lesion,
which looked perhaps at a midsegment between 2 previous stents, and a lesion
after the last stent perhaps representing a geographic miss of the
previously placed stent. The right coronary artery showed an 80% mid
lesion, which appeared to be in-stent restenosis.
2. Intraaortic balloon pump placed.
3. Stenting of 2 lesions in the circumflex with 3.5 x 24 Promus stent.
4. Stenting of a 90% LAD with a 3.0 x 16 Promus Element stent.
5. Stenting of an 80% LAD with a 3.0 x 16 stent, post dilated with a 3.25.
6. Angiograms post of all lesions showed markedly improved arteries.
Elizabeth M., CCS, CPC, ICD-10 CM/PCS
Multi Specialty Coder/Compliance Auditor/ICD-10 Educator