# Another Cath plus



## nancy.anselmo@ccrheart.com (Feb 15, 2013)

INDICATIONS: Angina pectoris.

Left heart catheterization, selective coronary angiography, left ventriculography with percutaneous intervention of the mid and distal left circumflex as well as bifurcation stenting with kissing balloon of OM1 

HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old with history of hypertension, dyslipidemia, PAD with CKD and diffuse coronary disease with multiple previous percutaneous interventions in the past who presents with symptoms concerning for 
angina and had a high risk stress test with multiple wall motion abnormalities. He is referred for diagnostic angiography due to high risk stress test despite maximal medical therapy.

PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. The right wrist was prepped in the usual sterile fashion and 2% lidocaine infused 
subcutaneously until adequate anesthesia was obtained. Right radial artery was accessed using modified Seldinger technique of which a 6 French 250 mm Glidesheath was placed without complication. Diagnostic 6 French Jacky catheter as well as a JL4 
diagnostic catheter was used to perform selective coronary angiography, left heart catheterization, left ventriculography. At the conclusion of the procedure, a TR band was used for hemostasis.

HEMODYNAMICS: Left ventricular end-diastolic pressure measured 7 mmHg. There was no transaortic gradient on pullback.

LEFT VENTRICULOGRAPHY: Demonstrated moderate left ventricular dysfunction, ejection fraction 40%.

CORONARY ANGIOGRAPHY:
LEFT MAIN: Mild disease.

LAD: Moderate diffuse disease with patent stent seen in the midvessel segment. There was a small diagonal with mild disease.

LEFT CIRCUMFLEX: Large, dominant distribution. There was a bifurcation stent seen in the proximal left circumflex leading into the first marginal. Just after this in the mid left circumflex, there was an 80% focal stenosis. There also appeared to be 
stenosis at the bifurcation. In the first marginal, there was a large bifurcating vessel that gave off first and second marginal of which there was a 90% bifurcation stenosis compromising the ostium of both rami.

RCA: Nondominant and severely diffuse disease.

SUMMARY: Severe coronary artery disease, left circumflex distribution with restenosis and high-grade de novo stenosis of the first and second marginal.

Due to the patient's clinical presentation and angiographic findings, it was decided to proceed with angioplasty.

INTERVENTION: Angiomax was used for effective anticoagulation. An EBU 3.75 guide catheter was used to intubate the left main coronary artery. Initially a Runthrough wire was placed to the second marginal and an ATW wire was then attempted to be 
navigated to the first upper branch, however, upon attempts to pass a balloon, it would not pass indicating stenosis within the bifurcation of the previously placed stents. A 2.5 balloon was then used to dilate over the Runthrough wire and a PILOT wire 
was then used to navigate across the stenosis about the bifurcation of the previously placed stents into the lower rami of the second marginal. An ATW wire was then redirected and placed down into the distal circumflex into the left PDA. A 2.5 balloon 
was used to dilate the focal in-stent restenosis seen in the mid left circumflex that fed the left PDA to 16 atmospheres with an excellent angiographic result. Attention was then drawn to the bifurcation lesions in the marginals. A 2.5x14 Resolute 
drug-eluting stent was then deployed across the bifurcation into the lower branch of the second marginal and a 2.5 balloon was used in a kissing fashion to dilate the ostium of the upper branch of the first marginal. There was TIMI-III flow with mild 
residual stenosis in the upper branch.

SUMMARY: Successful percutaneous intervention of the mid left circumflex and first and second marginals of the stent to the marginal and balloon angioplasty to the other marginal as well as balloon angioplasty to the mid left circumflex.

93458-26-59
92928-LC
92920
92921 What modifiers do I use on the ballons?
Thanks for your help


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## theresa.dix@tennova.com (Feb 18, 2013)

This wasnt easy. It looks to me that everything was done in the LC.


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## nancy.anselmo@ccrheart.com (Feb 18, 2013)

So does that mean I have the correct codes or am I way off


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## theresa.dix@tennova.com (Feb 19, 2013)

nancy.anselmo@ccrheart.com said:


> So does that mean I have the correct codes or am I way off



Nancy,
 I think you have the correct codes


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