# Pci/stent - selective coronary



## rparikh (Apr 28, 2014)

I would like know if these are correct codes: 93459-26-59, 92937, 92933, 92920


PROCEDURES PERFORMED:
1. Left heart catheterization with selective coronary and left
ventricular angiography.
2. Angiography of the saphenous vein graft to the left anterior
descending artery.
3. Rotational atherectomy of the ostial left circumflex artery.
4. Rotational atherectomy of the ostial left anterior descending
artery.
5. Cutting balloon angioplasty of the ostia of the left anterior
descending artery and left circumflex arteries.
6. PCI (percutaneous coronary intervention) with stenting of the distal
left main coronary artery and ostial/proximal left circumflex artery
with a 3.5 x 15 mm Xience Everolimus eluting stent.
7. Kissing balloon angioplasty of the distal left main coronary artery
bifurcation.
.
1. Severe native multivessel coronary artery disease with 100%
occlusion of the mid left anterior descending artery, 100% occlusion of
the mid right coronary artery and 90% stenosis of the ostial left
circumflex artery.
2. Patent saphenous vein graft to the left anterior descending artery.
3. Evidence of ischemic cardiomyopathy with ejection fraction around
30-35%.
4. LV (left ventricular) diastolic dysfunction with LVEDP (left
ventricular end-diastolic pressure) of 17-20 mmHg.
5. Moderate mitral insufficiency (likely ischemic).
6. Successful rotational atherectomy, cutting balloon angioplasty and
PCI and stenting of the distal left main coronary artery and the ostial
left circumflex artery using a 3.5 x 15 mm Xience Everolimus eluting
stent.
7. Successful rotational atherectomy, cutting balloon angioplasty and
kissing balloon angioplasty of the distal left main coronary bifurcation
of the ostial LAD (left anterior descending) circumflex artery.
8. Successful kissing balloon angioplasty of the distal left main
coronary artery bifurcation.
OPERATIVE FINDINGS:
CORONARY ANGIOGRAPHY:
The left main coronary artery demonstrates fluoroscopic calcification
but is widely patent. The left main coronary bifurcates into left
anterior descending and left circumflex arteries. The left circumflex
artery demonstrates an ostial 90% hazy eccentric stenosis. This is very
likely the culprit lesion responsible for the patient's symptoms. The
stent in the proximal circumflex is widely patent. The mid circumflex
artery demonstrates eccentric 30-50% calcific stenosis. There is no
significant disease seen in the rest of the circumflex system.
The left anterior descending artery demonstrates a 80-90% ostial
stenosis. The mid segment of the vessel demonstrates heavy
calcification and is 100% occluded. The distal LAD is seen filling via
a patent saphenous vein graft.
The right coronary was 100% occluded in its mid segment. There are
bridging collaterals (right to right) seen. The PD RCA is seen filling
quite nicely via a large septal perforator branch coming off the LAD.
LEFT HEART CATHETERIZATION WITH LEFT VENTRICULAR ANGIOGRAPHY:
The LV angiogram demonstrates moderate LV cavity dilatation with global
hypokinesis. The visual estimated ejection fraction is around 30-35%.
The LVEDP is 17-20 mmHg. There is probably moderate mitral
insufficiency. There is no pressure gradient across the aortic valve on
catheter pullback.
PERCUTANEOUS CORONARY INTERVENTION:
Successful rotational atherectomy, cutting balloon angioplasty and
stenting with a 3.5 x 15 mm Xience stent to the distal left main
coronary artery and ostium of the left circumflex artery: 90% ostial
circumflex stenosis reduced to 0% post stenting. The stent was
post-dilated with a 4 x 12 mm NC balloon up to 10-12 atmospheres.
Successful rotational atherectomy followed by cutting balloon
angioplasty and kissing balloon angioplasty of the ostium of the left
anterior descending artery: 80-90% stenosis reduced to around 20%.
INDICATIONS AND BRIEF HISTORY:
The patient is an 80-year-old Latino gentleman with ACS/NSTEMI. He has
been having recurrent chest pains. The patient was about to be
discharged with conservative medical management on 04/15/2014 when the
patient started complaining of more anginoid chest pains. His troponin
rose to around 3.5 following that event. I was then consulted for
possible angiography and percutaneous intervention. The patient was
having stuttering chest pains all through yesterday. He received 2
units of packed red cell transfusions. No source of active bleeding has
been found. The patient has a history of known coronary artery disease
with previous bypass surgery and PCI and stenting of the left circumflex
artery in 12/2012. He is chronically on aspirin and Plavix, which he
tolerates quite well. The exact cause of the anemia is unknown. The
patient also has renal insufficiency. I spoke to the patient and his
daughter. The patient has dementia but he indicated that he wanted to
proceed with the procedure. I spoke to his daughter Angelica over the
phone in detail regarding the procedure and all the pros and cons. The
chance of renal failure requiring dialysis, stroke or even death was
discussed. I also indicated to the patient's daughter the importance of
the procedure given the fact that the patient has been having recurrent
chest pains and clearly had shown signs of non-ST segment elevation
myocardial infarction which puts him at increased risk of cardiovascular
death. The patient's daughter advised me to proceed. Prior verbal and
written informed consents had been obtained from him.
DESCRIPTION OF PROCEDURE:
Both the groins were prepped and draped in the usual sterile fashion.
Lidocaine 1% was infiltrated in skin and subcutaneous tissue of the
right groin for local anesthesia. A 6 French sheath was placed in the
right femoral artery using modified Seldinger technique. Selective left
and right coronary angiography was performed using 6 French JL4 and 6
French JR4 diagnostic catheters respectively. Multiple cineangiographic
images of the left and right coronary systems obtained in standard
projections. Contrast 7-10 mL was used to do each image. A 6 French
pigtail catheter was passed into the LV cavity. After recording
pressures, we performed an LV cineangiogram in 30 degree RAO projection.
Nonionic contrast 25 mL was injected at a rate of 15 per second. There
was no pressure gradient across the aortic valve on catheter pullback.
The saphenous vein graft to the left anterior descending artery was
cannulated with a 6 French JR4 diagnostic catheter. The graft was
imaged in multiple projections and was found to be widely patent
throughout its length.
The left internal mammary artery graft to the LAD was also cannulated
selectively with a 6 French JR4 diagnostic catheter. A small selective
contrast injection revealed that the left internal mammary artery had
not been utilized for bypass surgery.
The 6 French right groin sheath was upsized to a 7 French sheath. The
left main coronary artery was cannulated with a 7 French EBU 3.5
angioplasty guide catheter. We decided to perform rotational
atherectomy of the calcified lesion in the distal left main coronary
artery, proximal/ostial circumflex and proximal/ostial LAD. A
Rotafloppy wire was passed down the left circumflex artery and
positioned in the distal obtuse marginal artery. A 1.75 mm burr was
platformed with 175,000 RPMs. We then passed the bur across the lesion
in the distal left main coronary artery and ostial/proximal circumflex
artery. The bur was run back and forth several times. Subsequent
angiograms revealed significant improvement in the ostial circumflex
lesion after the rotational atherectomy. We then took the wire out of
the circumflex artery and repositioned the proximal LAD. We then
performed rotational atherectomy of the diseased ostium of the LAD.
Following this, the rotational atherectomy wire and the bur were
removed. We then passed 2 short BMW wires down the left anterior
descending artery and the left circumflex arteries. We performed
cutting balloon angioplasty of the ostia of the LAD and the circumflex
using a 2.5 x 6 mm cutting balloon. Several balloon inflations were
performed with maximum inflation pressure of 6-7 atmospheres. Leaving
the wire in the LAD, we stented the distal left main coronary artery and
the ostium of the circumflex artery using a 3.5 x 15 mm Xience stent.
The wire was pulled back and we crossed back into the LAD through the
stent struts. We then performed kissing balloon angioplasty. We then
post-dilated the stent with a 4 x 12 mm NC balloon. Several balloon
inflations were performed, maximum inflation pressure of 12 atmospheres.
We then performed kissing balloon angioplasty using a 3 x 12 mm NC
balloon in the distal left main and ostial LAD location and the same 4 x
12 mm NC balloon in the distal left main and ostial circumflex location.
Both the balloons were inflated simultaneously with inflation pressures
of around 5-6 atmospheres in each of the balloons. The final angiograms
performed with and without the wires inside the vessel revealed an
excellent result. There were no complications. There was no residual
stenosis seen at the treated sites.
The patient tolerated the entire procedure quite well. He was been
getting very restless and tried to sit up. He also wanted us to stop
the procedure ASAP. A brief right iliofemoral angiogram was performed.
The right femoral arterial sheath was removed and a Perclose/ProGlide
device was used to apply a suture to the right femoral arterial puncture
site. Excellent hemostasis was achieved. Prior to that we had
performed right iliofemoral angiogram to visualize the vessel. The
sheath was found to be entering into the right common femoral artery
above the bifurcation and there was no evidence of any complications in
spite of the fact that the patient was quite restless. He received a
total of around 200 mL of nonionic contrast.
RECOMMENDATIONS:
1. Post procedure hydration.
2. Plavix and aspirin to be continued. He received a 300 mg bolus of
oral Plavix following the stent procedure.
3. Aggressive risk factor modification.
4. Compliance with medications will be stressed to the daughter.
5. The patient will follow up with Dr. Shetty in about 7-10 days.

Thank You


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