# cath/stent    93461(59) 92937  92928 (59)



## maryann1224@bellsouth.net (Jun 18, 2013)

WOULD THESE BE THE APPROPRIATE CODES? ANY ASSISTANCE IS APPRECIATED, THANK YOU.


PROCEDURE: Standard radial access in the left radial artery
utilizing micropuncture kit and the modified Seldinger technique;
a standard femoral venous access utilizing the modified Seldinger
technique.  I placed a 5-French sheath in the left radial artery
and a #7 French sheath in the right common femoral vein. A
Swan-Ganz balloon floatation catheter was then advanced under
fluoroscopic guidance into the pulmonary artery.  A Tigg catheter
was used to cross the aortic valve. Simultaneous pulmonary
arterial and left ventricular saturations were obtained and sent
for analysis. I then performed thermodilution cardiac outputs.
Simultaneous left and right heart pressures were measured during a
pullback from wedge position to the right atrium. I performed a
hand injection ventriculogram. This was followed later in the case
by a power injection ventriculogram. We measured pullback across
the aortic valve and used the Tigg catheter for selective left and
right coronary angiography. We then used the Tigg catheter also
for selective left internal mammary angiography. We then proceeded
with the intervention as described below.

HEMODYNAMICS: Mean right atrial pressure is 4, RV pressure 24/4,
PA pressure 24/6 with a mean pulmonary arterial pressure of 12.
Wedge pressure was 10. LV pressure 103/7. Aortic pressure 103/46.
PA saturation is 74 with LV saturation of 98%. Fick cardiac output
7.1 with a thermodilution cardiac output 6.8.

VENTRICULOGRAM: Left ventricular systolic function is mildly
reduced and estimated overall ejection fraction of 45% with
hypokinesis of the anterolateral wall.

CORONARY ANGIOGRAPHY:

LEFT MAIN CORONARY ARTERY: Originates from the left coronary cusp.
It bifurcates into the left anterior descending coronary artery
and left circumflex artery. The left main coronary artery has mild
atherosclerotic plaquing up to an eccentric 20% plaque in its
distal third.

LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left anterior
descending artery is severely diseased, as is the major diagonal
vessels. In the proximal LAD there is the first diagonal vessel
which is a 2.25 mm vessel in diameter. It is subtotally occluded
proximally. The second diagonal vessel is a moderate to large size
vessel and has a chronic total occlusion proximally with bridging
left to left collaterals. After D2 the mid LAD has severe disease
with diffuse 80% stenosis. There is competitive flow into the
distal and apical LAD. The distal and apical LAD are imaged
through injection of the mammary artery as described below.

LEFT CIRCUMFLEX CORONARY ARTERY: The left circumflex artery gives
rise to a moderately large first obtuse marginal vessel with a 95%
stenosis proximally. After that the circumflex gives rise to a
large atrial branch and then the circumflex continues in the
AV-groove giving off a posterolateral obtuse marginal vessel. That
mid to distal circumflex has a 95% napkin ring lesion.

RIGHT CORONARY ARTERY: Originates from the right coronary cusp. It
is an anatomically dominant vessel. It is moderate to large size
in caliber with a 60% stenosis at the ostium of the posterior
descending artery. All vein grafts known to be occluded.

The mammary artery to the LAD is patent; however, immediately
distal to the anastomosis of the mammary artery on the mid LAD,
the mid and distal LAD is subtotally occluded.

INTERVENTION: Based on findings at diagnostic catheterization of
severe three-vessel coronary disease with failure of 5 out of 5
grafts, although the mammary graft remains patent to the LAD, a
decision was made to proceed with percutaneous revascularization
if possible. We did engage the mammary artery with a mammary guide
catheter and administered Angiomax used to run through wire to
cross the lesions in the mid to distal and apical LAD. I then used
a 2.5 x 12 mm balloon to dilate the LAD. I deployed a 2.25 x 30 mm
Integrity Resolute in the mid to distal LAD. This was deployed
with two inflations to a maximum of 12 atmospheres. Following
stent deployment, there was residual severe disease and a decision
was made to stent this as well. This was stented with a 2.25 x 26
mm Integrity Resolute after angioplasty with the 2.25 stent
delivery balloon. There was end-to-end overlap of the proximal
edge of the second stent in the distal edge of the first stent and
final angioplasty was at 12 atmospheres. After removal of balloons
and wires, we had TIMI-3 flow with no perforation, dissection or
distal embolization.

Attention was then turned to the obtuse marginal vessel. We
engaged the left main with an EBU 4.0 6-French guide catheter and
advanced the run through wire into the posterolateral obtuse
marginal vessel. We were unable to cross this lesion. We did try
several other wires but were never able to cross into the distal
circumflex. We turned our attention then instead to OM1. This was
cross with the run through wire; angioplasty with a1.5 x 20 mm and
then a 2.0 balloon. I was then able to position an Integrity
Resolute 2.5 x 30 mm stent from the ostium of OM1 distally.  This
was deployed with two inflations to 12 atmospheres and after
removal of balloons and wires, we had TIMI-3 flow with no
perforation, dissection or distal embolization. I then made
several attempts with multiple wires to cross the occlusions in D1
and D2, however, these turned out to be chronic total occlusions
that I could not cross even with a Whisper wire and back up
support with a Covidien angled microcatheter.  At this point, as
the patient remained on Angiomax. We decided against using stiffer
wires and performed final angiography which demonstrated TIMI-3
flow with no perforation, dissection or distal embolization


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## TWinsor (Jun 18, 2013)

Looks right to me. You will need the 26-59 for the 92461

HTH !


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## maryann1224@bellsouth.net (Jun 21, 2013)

ok great!


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