# Coded correctly? Cpt codes at bottom



## OPENSHAW (May 24, 2013)

Preoperative diagnosis:

1.  Coronary artery disease
2.  Status post aortocoronary bypass
3.  Abnormal pharmalogical mibi
4.  Morbid obesity

postoperative diagnosis:

1.  Coronary artery disease
2.  Status post aortocoronary bypass
3.  Abnormal pharmalogical mibi
4.  Morbid obesity

operations performed

1.  Left heart cath
2.  Selective right and left coronary arteriogram
3.  Selective saphenous vein graft to the right coronary artery
4.  Arteriogram to the saphenous vein graft to the right coronary artery
5.  Selective arteriogram of the saphenous vein graft to the obtuse marginal 1, obtuse marginal 2, and obtuse marginal 3
6.  Subclavian arteriogram
7.  Left internal mammary artery arteriogram
8.  Saphenous vein arteriogram
9.  Thoracic aortogram
10.  Abdominal aortogram

reason for the procedure:  The patient has been having episodes of retrosternal chest pain with radiation to the neck accompanied with shortness of breath.  The patient underwent a pharmalogical mibi, this showed evidence of inferior scar with evidence of apical ischemia and inferior ischemia.  Because of the above findings, it was decided to proceed with intervention.

Description of the procedure:  After informed consent, the right groin was prepped in the usual sterile fashion which was done.  First a regular cook needle was tried to be placed in the right femoral artery with much difficulty.  It was not possible to do it with these needles, so a 9-cm needle was then attempted to be placed in the right femoral artery.  However after multiple attempts, it was not possible to cannulate the right femoral artery.  Also an ultrasound needle was also utilized and even with the ultrasound needle, it was not possible to cannulate the right femoral artery.  It was then decided to proceed to the left side of the patient and the left femoral artery was then cannulated with some difficulty.  The whole episode took aaproximately 45 minutes to an hour more than usual because of the bodily habitus of the patient which he described as morbid obesity.  After this was done, the case was continued from the left side.  The 1st catheter was a jl-4; however, it was not possible to place selectively in the left coronary, so the next catheter utilized was an angled pigtail which was placed under hemodynamic monitoring into the left ventricle and left ventriculogram was performed.  The catheter was withdrawn from the left ventricle and hemodynamic monitoring to the aorta and there was no gradient.  The next catheter utilized was a jl-5.  It was not possible to place this catheter in the ostium of the left coronary.  Therefore, this catheter was changed over a wire to a jl-4.  The jl-4 was then placed in the ostium of the left coronary and several views of the left coronary were obtained.  This catheter withdrawn over the wire to a jl-4.  This was placed in the ostium of the right coronary and right coronary was obtained.  The catheter was then rotated and placed in the ostium of the right coronary artery graft and several views of the right coronary artery graft were obtained.  Catheter was then rotated and placed in the ostium of the saphenous vein grft to the obtuse marginal branch of the circumflex.  Several views of this saphenous vein graft were obtained.  Because it was then withdrawn and exhibited in the subclavian, a subclavian arteriogram was performed.  After this was done, a long j-wire was utilized and the right coronary artery catheter was withdrawn over the j-wire and a lima catheter was placed in the subclavian and advanced to the lima and lima arteriogram was performed.  Because the patient had some st-segment depression in the lead #1 and some st-segment elevation in lead 3 after injecting the left coronary, it was decided to inject the left coronary again.  So a jl-4 was again inserted into ostium of the left coronary and the left coronary was injected again.  After it was done, because of the presence of the graft, ascending aortogram was performed to look for extra grafts; however, no extra grafts were found and because of difficulty of entry, an abdominal aortogram was performed and followed to both iliac artery and this showed nonocclusive disease.  After this was done, the patient tolerated the procedure well and was sent to the recovery room in stable condition.  He is to have the arteriotomy closed with syvek patch.

Hemodynamic monitoring:  The aortic pressure was 130/80.  The left ventricular pressure was 130 and the end-diastolic pressue was 6 to 8

angiographicefindings:  The right coronary was injected, it was viewed and it was only partially occluded.  Right coronary artery graft was injected in several views and exhibited a diffuse disease in the graft with diffuse disease in the distal in the distal rca-pda.  The left coronary artery was injected in several views, it showed a small left main and the lad was 100% occluded and the circumflex was 100% occludedwith a diagonal that was patent and had diffuse disease.  The saphenous vein hgraft toe marginal; graft 1 and 2 and 3 was injected in several views, that it was injected in ap, ap caudal, rao caudal, rao cranial, ap cvranial, and rao and it showed a very patent graft to om-1, om-2, and a very small graft to the rest of the circumflex that was probably less than 1 mm in diameter.  The lima was injected in several views that is in the lao, ap, and rao projection and it showed inferior akinesis with an ejection fractionm of 40%.  The procedure was very difficult because of the morbid obesity of the patient. It was impossible to enter the right femoral artery and it was very difficult to enter the left femoral artery.  Took approximately 1 hour more than normal because of the tremendous morbid obesity of the patient.

93459-26,  dx. 414.00, V45.81
93567,  dx. 414.00, V45.81


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