# LHC WITH RT Ridial artery vascular access



## rparikh (Mar 13, 2012)

someone has  code for Ridial artery vascular access, I also wants to make sure these are the correct code for this repot: 93458-26, 75605-26, 75716-26

PROCEDURES PERFORMED:
1.  Right radial artery vascular access.
2.  Coronary angiography.
3.  Left heart catheterization with LV angiography.
4.  Thoracic aortography.
5.  Abdominal aortography with bilateral lower extremity runoff
angiograms.

POSTOPERATIVE DIAGNOSES:
1.  Coronary artery disease (see description below).
2.  Normal LV (left ventricular) systolic function.
3.  LV (left ventricular) diastolic dysfunction with LVEDP (left
ventricular end diastolic pressure) of 18 mmHg.
4.  Severe peripheral arterial disease with 50% stenosis in the distal
abdominal aorta, 100% chronic occlusion of the right common iliac
artery, 60% stenosis of the left common iliac artery, 80-90% stenosis of
the left common femoral artery at the site of graft anastomosis.
5.  Patent bilateral superficial femoral arteries and a 3-vessel runoff
into both legs.

CORONARY ANGIOGRAPHY:
There is significant fluoroscopic calcification in the left coronary
system.  The left main coronary artery bifurcates into left anterior
descending, left circumflex arteries.  The left circumflex artery
demonstrates eccentric 60-70% stenosis in its mid segment.  The left
anterior descending artery demonstrates eccentric 70-75% focal stenosis
in its midsegment, right at the site of takeoff of the 2nd diagonal
branch artery.  The 2nd diagonal branch artery demonstrates no
significant obstructive disease.  The distal LAD demonstrates no
significant obstructive disease.

The right coronary artery is a fairly large and dominant vessel which
demonstrates fluoroscopic calcification mid segment.  The mid right
coronary artery demonstrates eccentric 30-40% stenosis.  There is a
second 50-60% stenosis in the mid right coronary artery.  This does not
appear to be flow limiting.  The PLA and the PDA are large vessels, but
do not demonstrate any significant obstructive disease.

LEFT HEART CATHETERIZATION WITH LV ANGIOGRAPHY:
The LV angiogram demonstrates normal LV cavity size.  The post-PVC LV
ejection fraction is around 70-75%.  There does appear to be some LVH.
There is no mitral insufficiency.

THORACIC AORTOGRAPHY:
Thoracic aortogram demonstrates normal caliber thoracic aorta.

ABDOMINAL AORTOGRAPHY:
The abdominal aortogram demonstrates 50% eccentric stenosis of the
distal abdominal aorta just above the bifurcation of the iliac vessels.
The right common iliac artery is 100% occluded soon after its origin.
The left common iliac artery demonstrates 60% eccentric stenosis.  There
is a patent femoral-femoral bypass graft from the left common femoral
artery to the right common femoral artery.  The graft is widely patent.
However, at the site of anastomosis of the graft to the left common
femoral artery, the CFA demonstrates an 80-90% stenosis.  This certainly
is compromising flow to the left lower extremity.

ABDOMINAL AORTOGRAPHY WITH BILATERAL LOWER EXTREMITY RUNOFF ANGIOGRAMS:

The lower extremity runoff angiograms performed in the right and left
lower extremities separately shows a patent superficial femoral arteries
on both sides.  The popliteal arteries on both sides are also patent.
There seems to be 3-vessel runoff in both legs.

INDICATIONS AND BRIEF HISTORY:
The patient is a 59-year-old white woman undergoing preoperative cardiac
evaluation for large pelvic mass seen on imaging studies.  The patient
is planning to have surgery.  She has known peripheral arterial disease
and had undergone femoral-femoral bypass surgery in the past.  The
patient underwent a stress echocardiogram which showed significant
restriction in her functional capacity and possible ischemia of the
anterolateral walls.  The patient was advised coronary angiography with
possible revascularization.  All the risks and benefits associated with
the procedure were explained.  We also decided to perform a peripheral
angiogram given the fact that the patient has claudication pain and easy
fatigability in both legs.  All the risks and benefits associated with
the procedure were explained.  Written informed consent was obtained.
The patient requested us to use her right wrist (radial artery access)
for the procedure.

DESCRIPTION OF PROCEDURE:
The right wrist was prepped and draped in the usual sterile fashion.
Intravenous Versed and fentanyl were used for sedation.  Lidocaine 1%
was infiltrated in the skin and subcutaneous tissue over the right
radial artery for local anesthesia.  Using a short radial artery access
needle, we managed to get front wall access to the radial artery.  A
0.018 inch short guidewire was carefully threaded into the radial
artery.  We then passed a 5 French radial sheath into the right radial
artery over the 0.018 inch guidewire.  After obtaining access, we
injected the "radial artery cocktail" consisting of heparin, verapamil
and nitroglycerin.  The right coronary artery was initially cannulated
using a 5 French AL1 diagnostic catheter passed over a 0.038 inch J tip
guidewire under fluoroscopy.  The right coronary artery was imaged in
multiple projections.  We then managed to cannulate the left coronary
artery successfully with the same AL1 diagnostic catheter.  Multiple
cineangiographic images of the left coronary systems obtained in
standard projections, 7-10 mL of contrast was needed to do each image.

A 5 French pigtail catheter was passed into the LV cavity.  Nonionic
contrast, 20 mL, was power injected at a rate of 15 mL per second.
There is no pressure gradient across the aortic valve on catheter
pullback.  The LV cineangiogram was performed in the 25 degree RAO
projection.  We then performed a thoracic aortogram by power injecting
30 mL of nonionic contrast at a rate of 17 per second.  The thoracic
aortogram was performed in the 45 degree LAO projection.  The pigtail
catheter was passed into the abdominal aorta over the wire under
fluoroscopic guidance.  The catheter was positioned above the
bifurcation.  We then performed an abdominal aortogram by power
injecting 30 mL of nonionic contrast at a rate of 15 per second.  We
managed to study the iliac arteries and the status of the grafts.  We
then decided to perform runoff angiograms.  Separate contrast injections
were made into the aorta through the pigtail catheter and we imaged both
the legs from the groin up to the ankles, separately for the 2 sides.
The right radial artery access sheath was removed.  Manual pressure was
applied and a compression device was applied to the right radial
puncture site.  Excellent hemostasis was achieved.  No complications.

Results of the angiogram were conveyed to the patient.

CONTRAST:
The patient received a total of around 246 nonionic contrast.

RECOMMENDATIONS:
1.  Increase metoprolol to 50 mg a day.
2.  Continue the rest of medications as before.
3.  Proceed with pelvic surgery with the understanding of a small to
modest risk of adverse cardiovascular events.  However,
revascularization therapies of any sort would delay her procedure.  The
patient has a large pelvic mass and I think the best option for her at
this point would be to proceed with surgery and consider coronary
revascularization procedures later.
4.  With regards to her symptomatic peripheral artery disease, we should
consider PTA and stenting of the stenosis of the left common iliac
artery and the left common femoral artery after her pelvic surgery.
Both these locations would take stents.
5.  The patient may stop her aspirin for about 5-7 days prior to surgery
and needs to be started soon afterwards.  She will have to continue her
beta-blockers, ACE inhibitor and statin therapy indefinitely to minimize
risk of adverse cardiovascular events.  Like mentioned before, the
beta-blocker therapy can be increased prior to surgery, to minimize risk
of adverse cardiac events with the stress of surgery.

Thanks


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## rparikh (Apr 12, 2012)

*need help*

I still need help with coding.

Thank you


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## ebarnett (Apr 12, 2012)

*LHC WITH RT radial artery vasculr access*

93458/26 for the left heart cath, coronary angiography and vgram
75635/5926 for abdominal aortogram with run off or G0278 if Medicare patient
and I think...71250 for the thoracic angiography


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## Robbin109 (Apr 22, 2012)

Wouldn't the thoracic angio be 75605?


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