# Lhc with stent placement scenario



## em2177 (Mar 13, 2012)

*IS THIS CORRECT: 93458,92980 LD?* 

PROCEDURE(S) PERFORMED:
1. Left heart catheterization and coronary angiography.
2. Angioplasty of the 90% proximal intermediate lesion with subsequent
difficulty deploying stent.
3. Rotablator of the ostium of the left anterior descending (LAD).
4. Final stent placement, 2.75 Promus Element stent dilated to a 3.0.

*PROCEDURE:* The patient was prepped and draped in the usual fashion and brought
to the catheterization laboratory having been premedicated with Xanax and
Benadryl. Using 2% local Xylocaine, the right femoral region was anesthetized.
Using a single-wall technique, the right femoral artery was entered.
Introducer sheath was placed, through which a 4 left Judkins was advanced to
the ostium of the left coronary artery. Several hand injections visualized the
artery in various projections.
This catheter was removed and replaced with a Williams right catheter, which
was advanced to the ostium of the right coronary artery. Several hand
injections visualized the artery in various projections.
At this juncture, attention was turned toward intervention of the 90%
intermediate lesion. Weight-adjusted heparin was given, and an 0.014 S'port
wire was advanced down the artery into the distal vessel. A 2.0 balloon was
advanced to the point of the lesion and fully expanded. This was then
withdrawn. Attempts were made to place a 2.75 stent, but this would not go
beyond the ostium of the LAD. Therefore, this was removed and a GuideLiner was
placed inside the 4 left guide. Again attempts to advance the stent were
unsuccessful.
At this juncture, it was elected to do rotablator with a small bur to see if we
could displace the calcium in the ostium of the LAD. A 1.25-mm bur was
prepared, and we changed the wire out for a rotablator wire over a balloon.
Several runs were made with a Rotablator wire. It was very difficult to
position the burr, because there was not much space, and the burr tended to get
caught in the calcium and would thrust forward.
Therefore, ultimately having gone through the lesion several times, it was
elected to pull the rotablator burr and again try to place the stent. With the
help of a buddy wire, we were able to get the stent beyond the point of the
calcification and into the vessel and fully expand it to 2.75 and then
ultimately post dilate it with a 3.0.
Angiograms post showed a markedly improved lesion without significant residual.
There was still marked calcification in the ostium of the circumflex and LAD
and distal left main.
The patient was given weight-adjusted heparin prior to the procedure and was
also given intracoronary nitroglycerin. At one stage during the procedure he
felt somewhat nauseated and was given Zofran at 4 mg. He was also given 600 mg
of Plavix while he was on the table. At the end of the procedure the catheters
were removed and the sheath was removed. Hemostasis was achieved with
Angio-Seal.

*ANGIOGRAPHIC DATA:*
1. Coronary artery disease with marked calcification in the LAD, circumflex,
and intermediate coronary arteries. The left main is somewhat smaller than
expected. There is marked calcification at the distal end and the proximal
of the LAD, which creates somewhat of a filling defect. This is also noted
in the proximal portion of the circumflex. The LAD has some plaquing and
some slight narrowing at the level of the diagonal, but without significant
obstruction. The diagonal is patent. The circumflex shows no significant
obstruction. The intermediate branch shows a 90% lesion in the proximal
vessel. The right coronary artery shows a widely patent proximal stent.
There are multiple lumpy, bumpy areas throughout the right coronary artery
but no significant obstruction. This is a very large artery.
2. Percutaneous coronary intervention of the intermediate with balloon
angioplasty and rotablator with a 1.25 bur and subsequent placement of a
2.75 stent, Promus 16, post dilated to a 3.0 balloon. Angiograms post
showed a markedly improved lesion area.


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## Jess1125 (Mar 13, 2012)

em2177 said:


> *IS THIS CORRECT: 93458,92980 LD?*
> 
> PROCEDURE(S) PERFORMED:
> 1. Left heart catheterization and coronary angiography.
> ...



Left heart cath is stated in the procedure listing but I don't see any mention of the aortic valve being crossed and the physician being in the left ventricles. I just see the coronaries and intervention. 

93454.26.59/92980.LD

Jessica CPC, CCC


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