# Angio/stent/rotablation?



## maryann1224@bellsouth.net (Aug 5, 2013)

NEED SOME ASSISTANCE PLEASE, WOULD  92928, 92929, & 92933 BE CORRECT?    THANK YOU FOR YOUR ASSISTANCE......            After obtaining informed consent, the patient was
transported in the nonsedated condition to the cardiac
catheterization suite. The patient was prepped and draped in a
sterile fashion. Lidocaine 2% was used to infiltrate the skin and
subcutaneous tissue overlying the right radial artery after an
Allen's test demonstrated adequate collateral circulation.
Utilizing a micropuncture kit, I placed a #6 French sheath. I used
a #6 French EBU-3.75 guide catheter for left coronary angiography.
We then proceeded with the intervention. Angiomax was administered
and a run through wire was advanced through the lesion in the
circumflex artery. This was an 80% stenosis of a 3 mm vessel. It
involves the origin of the first obtuse marginal which had an
ostial 80-85% stenosis. I performed angioplasty on the circumflex
artery and then due to the large size of the obtuse marginal
vessel and the severe stenosis at its origin, the decision was
made to angioplasty this lesion as well. I used a 2.5 balloon and
after angioplasty I placed an Integrity Resolute 2.5 x 12 mm
drug-eluting stent into OM1 backed up against a balloon placed in
the circumflex artery over the run through wire. Having carefully
positioned the stent, it was deployed and then I crushed any
struts protruding into the circumflex artery with the balloon in
the circumflex artery and I then replaced my balloons with a 3.0 x
22 Integrity Resolute which was placed in the circumflex artery,
jailing the obtuse marginal vessel. This stent was deployed with
two inflations to 12 atmospheres after removal of my BMW wire from
OM1. I then recrossed through the stent struts and out into OM1
with the run through wire and placed the BMW wire into the distal
circumflex. I crossed through the stent struts and utilizing 2.5 x
12 drug stent delivery balloon and placed a 3.0 x 22 mm Integrity
Resolute in the circumflex artery.  Individual branch inflations
were performed to 12 atmospheres. I then performed kissing balloon
angioplasty to 8 atmospheres in both balloons. After removal of
balloons and wires, we had no residual stenosis, TIMI-3 flow with
no perforation, dissection or distal embolization.

Attention was then turned to the diagonal vessel.  Utilizing the
run through wire, I was able to cross the 95% stenosis in the
proximal first diagonal vessel, however, I could not get anything
larger than a 1.5 mm balloon to cross into the napkin ring
calcific lesion in the proximal diagonal vessel. We did perform
high pressure angioplasty with two separate balloons; both
balloons burst over 22 atmospheres and still we could not cross
the lesion. The decision was made therefore to terminate
intervention on the diagonal vessel and balloons and wires were
removed. However, the patient experienced chest discomfort. Repeat
imaging demonstrated occlusion of the diagonal vessel. Despite
administration of nitroglycerin, the vessel remained closed and I
tried a second time to open it. I was able to successfully wire
the lesion and then again with a 1.5 mm balloon and performed
angioplasty we restored TIMI-3 flow and then terminated the
procedure. After terminating the procedure but before the patient
left the room, she continued to have chest pain that did not
respond to IV nitroglycerin and a decision was made to proceed
with rotablation of the diagonal vessel. She was prepped and
draped again in a sterile fashion and Lidocaine was used to
infiltrate the skin and subcutaneous tissue overlying the right
common femoral artery. Percutaneous access was obtained and I used
a 7-French EBU 4 to engage the left main coronary artery. I was
able to wire the diagonal vessel and tried first with a 1.5 mm
balloon to exchange my long BMW wire for a rotafloppy however,
this was unsuccessful. I did replace the BMW wire and then
performed angioplasty with a 1.5 mm balloon, but were unsuccessful
in opening and I then tried a fine cross catheter but this also
would not cross the lesion and I ended up free wiring the diagonal
vessel with a rotafloppy. With the rotafloppy in place, we
performed rotablation initially with a 1.25 mm  Boston Scientific
balloon and then a 1.5 mm Boston Scientific balloon. Angioplasty
was then performed with a 2-0 Trek NC balloon and I was then able
to pass a second wire as a buddy wire beside the rotafloppy and
with that in place, I advanced a Promus Element 2.25 x 16 mm stent
into the diagonal vessel. This was carefully positioned and then
deployed with two inflations to a maximum of 16 atmospheres
following removal of the rotafloppy wire. I then administered
intracoronary nitroglycerin and we repeated angiography. This
demonstrated TIMI-3 flow with no residual stenosis in the diagonal
vessel.  Balloons and wires were all retrieved and final
angiography demonstrated TIMI-3 flow with no perforation,
dissection or distal embolization.


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