# Cerebral Angioplasty



## Hariharan (Sep 6, 2008)

Hi , Please code this report......

Cerebral angiogram and angioplasty

Clinical: right common carotid artery symptomatic restenosis in a
Patient with history of laryngeal carcinoma status post neck
Radiation and carotid stent placement

Following discussion of risks and benefits and alternatives, informed
Consent for these procedures was obtained from the patient through an
Interpreter. The procedures were performed under conscious sedation .
The patient was monitored throughout for ekg, blood pressure, and
Pulse oximetry. Then using standard techniques and a right common
Femoral approach a six french sheath was placed. After gaining
Vascular access at baseline act was drawn and followed throughout the
Case. Next a 6 french 90 cm envoy catheter was used for selective
Injections of right common carotid artery.

Right common carotid injections:
Ap, lateral and oblique views of the neck and skull base were
Obtained. Once again, there is an area of approximately 75 to 80%
Stenosis noted adjacent to the proximal aspect of the stent.
Additionally, there is an area of focal mid stent restenosis with a
Luminal stenosis of approximately 60 to 70% . The carotid bifurcation
Is widely patent. The visualized proximal eca and ica are
Unremarkable. There are visualize surgical clips adjacent to the
Vessel.
After selecting the appropriate working views a transcend exchange
Microwire was advanced past the stent restenosis using a rapid
Transit microcatheter. The microwire was advanced to the distal
Cervical internal carotid artery and the microcatheter was then
Removed.
A aviator 5 mm x 20 mm angioplasty balloon was prepared according to
Manufacture guidelines. The patient was given a bolus of heparin and
Started on heparin drip.
Right common caroitd artery angioplasties:
The balloon was then navigated across the proximal adjacent stent
Stenosis under continuous fluoroscopy and roadmap conditions. Once in
Optimal position the balloon was slowly inflated to 10 atmospheres
Under timed conditions. The balloon was then deflated and pulled back
Into the base catheter. Dsa runs were then obtained.
Repeat right common carotid artery injection:
There has been significant improvement in the proximal stenotic
Region. Lateral image of evaluation is limited by shoulder mass, but
Ap fluoroscopic runs demonstrate no residual luminal stenosis. A
Microwire is stable in position. The parent vessel is widely patent.
There is no evidence of dissection.
Right common carotid artery angioplasty:
The aviator 5 mm x 20 mm angioplasty balloon was once again advanced
Over the wire now more distally to the area of maximal in stent
Restenosis. Once in optimal position the balloon was inflated to 8
Atmospheres under timed conditions. The balloon was then deflated and
Removed. Dsa runs were then obtained.
Right common carotid artery injection:
There has been significant improvement in the angioplasted stenotic
Segment. There is less than 50% residual luminal stenosis. A
Microwire is stable in position. There is no evidence of vessel
Dissection.
Delayed common carotid artery injection:
Views over the head and neck were obtained. The angioplasty segments
Are widely patent. There is no evidence of platelet aggregation or
Filling defect. Views of the head were then obtained. The internal
Carotid artery is widely patent. There is significantly improved
Filling of the aca and mca. There is continued narrowing at the
Origin of the right a1. There is flash filling of the external
Circulation. There is no evidence of vessel cutoff or filling defect
To suggest embolic event.
The microwire was removed under continuous fluoroscopy to insure that
The stent is not disrupted.
The catheter was removed and then the sheath left in place. The
Heparin drip was left running overnight and discontinued in the
Morning. The patient was taken to a hospital bed for routine post
Procedure observation and care. There were no apparent complications.

Impression:
1. Approximately 75 to 80% proximal common carotid artery stenosis
Adjacent to right cca stent.
2. Approximately 60 to 70% mid in-stent restenosis.
3. Status post angioplasty of proximal cca stenosis without residual
Stenosis.
4. Status post angioplasty of mid in-stent restenosis with <50%
Residual stenosis.


Thanks
HariHaran CPC


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## Shirleybala (Sep 7, 2008)

Hi,

I arrived with this answers

36217-Cath gone upto internal carotid artery
75676- S&I
35475-Angioplasty intra stent stenosis
75962-S&I

What are your answers Hari, Share me ur ans

Thanks
Shirley


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## lisammy (Sep 8, 2008)

you will also need a -59 modifier to unbundle the angioplasty.


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## Hariharan (Sep 9, 2008)

Ya its correct except 36216 since only the microwire is advanced in to the cervical ica for supporting purposes, we cannot take this one as selective cathertization and 59 for 75676....


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