# subclavian angiography



## nancy.anselmo@ccrheart.com (Aug 20, 2012)

Left heart catheterization, selective coronary angiography, bypass graft angiography, subclavian angiography with percutaneous intervention of the vein graft to the LAD with placement of a Resolute drug-eluting stent

INDICATION: Angina pectoris, cerebrovascular disease with thrombosis, without mention of infarction.

HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old with severe coronary and peripheral vascular disease who presented with a TIA with balance issues. These symptoms resolved and he had a CT of his neck that demonstrated high-grade disease in his 
right vertebral that was subtotally occluded. His right carotid was patent with previous endarterectomy. His left carotid had a 70-90% stenosis and his left vertebral was noted to be compromised by potential proximal subclavian stenosis. He was to be 
referred for carotid surgery; however, elected to proceed conservatively and undergo a cardiac evaluation. After further historical review, he certainly does have progressive dyspnea on exertion and shortness of breath with intermittent chest pressure 
despite maximal medical therapy. He is therefore referred for coronary angiography.

PROCEDURE: Informed consent was obtained and the patient understood the risks, benefits and alternatives procedure and agreed to proceed with the procedure. The right groin was prepped in the usual sterile fashion and 2% lidocaine infused 
subcutaneously until adequate anesthesia was obtained. Right common femoral artery was accessed using modified Seldinger technique of which a 6 French 11 cm sheath was placed without complication. Diagnostic JL4 and JR4 catheters were used for coronary
angiography as well as left heart catheterization. At the conclusion of the procedure, an Angio-Seal was deployed without complication.

HEMODYNAMICS: Left ventricular end-diastolic pressure measured 12 mmHg. There was no transaortic gradient on pullback. 

Subclavian angiography based on the intermediate disease seen on previous angiography and known potential compromise of the vertebral system with recent TIA, it was decided to proceed with subclavian angiography. A JR4 catheter was placed selectively 
and multiple views were utilized that demonstrated a 60-70% proximal subclavian stenosis.

CORONARY ANGIOGRAPHY:
LEFT MAIN: Moderate disease.

LAD: The was totally occluded at the proximal level of the first septal. The distal vessel was moderately diffusely diseased and fed by a diseased bypass grafts. There was a diagonal system with a small, diffusely diseased diagonal.

CIRCUMFLEX: Totally occluded at the takeoff of a prominent marginal branch. This was subtotally occluded and fed by left-to-left collaterals. There is a 60% proximal first marginal stenosis.

RCA: Totally occluded proximally. The distal vessel was seen fed from left-to-right collaterals. 

VEIN GRAFTS: The vein graft to the marginal was known to be totally occluded. The vein graft to the right is known to be totally occluded. Vein graft to the LAD was selectively engaged and found to have a 99% eccentric tubular type B2 stenosis 
compromising the entire LAD and collateralized right circulation.

SUMMARY: Severe three-vessel coronary disease with high-grade native coronary disease as well as 1/3 bypass grafts available with a 99% stenosis seen in the only remaining bypass graft.

Based on the patient's clinical presentation with angina as well as potential upcoming high risk surgery, it was elected to proceed with angioplasty.

INTERVENTION: Angiomax was used for effective anticoagulation and eventually an AL1 guide catheter was used to intubate the vein graft to the LAD. A 3.5x5.0 FilterWire was placed distal to the lesion and a 2.5 balloon was used to predilate the lesion. 
Copious amounts of intracoronary Nipride were utilized in order to maintain effective flow and a 4.0x15 Resolute drug-eluting stent was then deployed to 14 atmospheres with an excellent angiographic result.

SUMMARY: Successful percutaneous intervention of the vein graft to the LAD with placement of a Resolute drug-eluting stent

CLINICAL PATHWAY: The patient was loaded on Plavix and maintained on aspirin and Plavix as well as a secondary prevention regimen. He will then be seeing Dr. Toufic Rizk for evaluation for his carotid disease and timing for intervention of his left 
carotid. 


92980-LD
93459-26-59 
and ? for the subclavian
Thank you Nancy


----------



## jewlz0879 (Aug 20, 2012)

Depending on if he did first or second order subclavian it would be:
Rt - 36216
OR 
Lt - 36215
75710-26

Also, I think it should be 93455 and not 93459. He does state a LHC was done but I do not see documentation that the aortic valve was crossed, ventriculogram is included, when performed. He did perform selective coronary angio with grafts but that's all I see.


----------



## Jess1125 (Aug 20, 2012)

jewlz0879 said:


> Depending on if he did first or second order subclavian it would be:
> Rt - 36216
> OR
> Lt - 36215
> ...



He has in the hemodynamics section an LVEDP pressure. 93459 is correct.

Jessica CPC, CCC


----------



## Jim Pawloski (Aug 20, 2012)

jewlz0879 said:


> Depending on if he did first or second order subclavian it would be:
> Rt - 36216
> OR
> Lt - 36215
> ...



I disagree with the heart cath choice.  In the hemodynamics section, there is a end-diastolic pressure, and that was obtained by a catheter in the LV.  You don't need an LV gram to have a LHC.  So yes code 93459.

Thanks,
Jim Pawloski, CIRCC


----------



## jewlz0879 (Aug 20, 2012)

Thank you, Jessica!


----------



## nancy.anselmo@ccrheart.com (Aug 21, 2012)

Thank you, I appreciate the help. Nancy


----------



## jewlz0879 (Aug 21, 2012)

Jim Pawloski said:


> I disagree with the heart cath choice.  In the hemodynamics section, there is a end-diastolic pressure, and that was obtained by a catheter in the LV.  You don't need an LV gram to have a LHC.  So yes code 93459.
> 
> Thanks,
> Jim Pawloski, CIRCC



Thanks, Jim. I know you don't have to have the LV but I didn't see the Hemodyanmics as I overlooked that. Thanks for the clarification!


----------



## carolt (Sep 5, 2012)

*stent to LAD*

What about the stent to the LAD?
Then you would need a 59 on the cath as well as the 26.


----------

