# Cath, Stent and Balloon



## nancy.anselmo@ccrheart.com (Jun 26, 2013)

INDICATIONS: Angina pectoris.

Left heart catheterization, selective coronary angiography, left ventriculography with percutaneous intervention of the first marginal with placement of a Resolute drug-eluting stent and balloon angioplasty of the lower lying left circumflex.

HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old with a history of diabetes, hypertension, dyslipidemia, tobacco abuse, previous coronary interventions in the past who presented with stuttering symptoms concerning for unstable angina. She was 
having angina at rest to start on low-dose of isosorbide in addition her antianginal therapy, however, still had persistent symptoms, and was referred for angiography.

PROCEDURE: Informed consent was obtained and the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. The right wrist was prepped in the usual sterile fashion and 2% lidocaine infused 
subcutaneously until adequate anesthesia was obtained. Right radial artery access modified Seldinger technique. A 6 French 250 mm Glidesheath was placed without complication. A 6 French TIG catheter was used to perform selective coronary angiography, 
left ventriculography and left heart catheterization. At the conclusion of the procedure, a TR band was used for hemostasis.

HEMODYNAMICS: Left ventricular end-diastolic pressure measured 8 mmHg. There was no transaortic gradient on pullback.

LEFT VENTRICULOGRAPHY: Demonstrated preserved left ventricular function, ejection fraction of 55-60%.

CORONARY ANGIOGRAPHY:
LEFT MAIN: Mild disease.

LAD: Mild to moderate diffuse disease. There is a first diagonal with mild disease.

LEFT CIRCUMFLEX: Had sequential stents seen in the mid and distal left circumflex placed in overlapping fashion that were otherwise patent. There was a prominent marginal branch that had an 80% ostial stenosis. it was jailed by the first stent.

RCA: Dominant vessel off prominent PL and PDA branches with mild disease.

SUMMARY: Critical single vessel coronary disease with high-grade disease seen in the first marginal.

CLINICAL PATHWAY: In light of the patient's aggressive presentation despite medical therapy, it was elected to proceed with angioplasty.

INTERVENTION: Angiomax was used for effective anticoagulation and an EBU 3.5 guide catheter was used to intubate the left main coronary artery. A Runthrough wire was then navigated through the previously placed stents. A 1.5 Apex push was attempted to
be navigated through; however, this was unsuccessful. A PILOT wire was then navigated through the previously placed stent struts across the stenosis into the distal marginal. Along this wire, the 1.5 push was attempted to be advanced; however, could 
not be effectively. Next, a 1.5 Apex Flex was then placed along the Runthrough wire and was successfully navigate across the lesion and dilated to 10 atmospheres. Next, a 2.5x12 balloon was then used to predilate the lesion further. A 2.5x18 Resolute 
drug-eluting stent was then deployed to 14 atmospheres. The PILOT wire was then redirected through the previously placed stent and a 2.5 noncompliant balloon was placed across the index lesion, and a 2.5 compliant balloon was placed in the lower lying 
marginal and across the stent struts, which was then dilated the in a simultaneous fashion in a kissing fashion with excellent angiographic result after a 14 and 10 atmosphere dilation respectively.

SUMMARY: Successful percutaneous intervention of the jailed first marginal with placement of a Resolute drug-eluting stent with balloon angioplasty of lower lying left circumflex with TIMI-III flow.

CLINICAL PATHWAY: We hope this will afford the patient symptomatic relief. Will focus on medical therapy. There was an observation of intermittent SVT during the procedure and her beta-blocker will be up-titrated as well. Smoking cessation will be 
highly encouraged due to the aggressive nature of the patient's disease.


Am I billing this correctly Thanks
92928
92920 or do I use 92921
93458-26-59


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## Jess1125 (Jun 26, 2013)

nancy.anselmo@ccrheart.com said:


> INDICATIONS: Angina pectoris.
> 
> Left heart catheterization, selective coronary angiography, left ventriculography with percutaneous intervention of the first marginal with placement of a Resolute drug-eluting stent and balloon angioplasty of the lower lying left circumflex.
> 
> ...



The 93458.26.59 and 92928 are correct. You would use 92921, though, yes for the PTCA. 

Jessica CPC, CCC


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## nancy.anselmo@ccrheart.com (Jun 26, 2013)

Thanks for your help


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