# Pci/stent



## rparikh (Apr 18, 2014)

I would like to know if these codes are correct CPT CODE  93459 (26) 59, 92928, 93567-59

REASON FOR PROCEDURE: 
The patient ___with coronary artery disease, 
diabetes mellitus and prior CABG who presented with generalized fatigue 
and weakness for about 2 weeks. She also had been having intermittent 
left-sided chest pain with radiation to the left arm for the same 
duration. She presented to the hospital at Selma with these complaints 
and ruled in for acute coronary syndrome with positive troponins. She 
was subsequently transferred to Community Regional Medical Center for 
diagnostic coronary angiography and possible intervention. 
DESCRIPTION OF PROCEDURE: 
After obtaining informed consent, the patient was brought to the cardiac 
catheterization laboratory. The right groin was prepared and draped in 
a sterile manner. Gowns, masks, caps and drapes were used to maintain 
strict sterile precautions. Intravenous Versed and fentanyl were used 
to attain moderate level of sedation. Lidocaine 1% was used for local 
anesthesia. 
Access to the right femoral artery was obtained with a Cook needle and a 
6 French standard sheath was introduced into the right femoral artery 
using modified Seldinger technique. A pigtail catheter was then 
advanced over the wire and placed in the LV cavity. After measuring LV 
pressures, LV gram was done and images were acquired in RAO projection. 
The catheter was then pulled back and after measuring pullback 
pressures, thoracic aortography was done and images were acquired in LAO 
projection. The catheter was then exchanged over a wire for a JL4 
catheter which was used to engage the left coronary artery. Selective 
coronary angiography of the left coronary artery was performed and 
images were acquired in various projections. The catheter was then 
exchanged over a wire for a JR4 catheter which was used to engage the 
right coronary artery. Selective coronary angiography of the right 
coronary artery was performed and images were acquired in various 
projections. The JR4 catheter was then used to perform selective 
angiography of the saphenous vein graft to the 1st diagonal branch. 
Next, the same catheter was used to engage the ostium of the left 
subclavian artery. The catheter was then exchanged over an exchange 
length wire for a LIMA catheter. Selective coronary angiography of left 
internal mammary artery was then done and images were acquired in 
various projections. The LIMA catheter was then removed over a wire. 
After reviewing images, the decision was taken intervene on the right 
coronary artery lesion and the diagonal lesion. A JR4 guide catheter 
was advanced over a wire and was used to engage the right coronary 
artery. Angiomax was given for anticoagulation. A short BMW wire was 
advanced through the guide past the lesion in the RCA and placed in 
distal and PDA branch. Angioplasty of 99% proximal to mid RCA stenosis 
was then done with 2.0 x 8 mm balloon with multiple inflations to 8 
atmospheres. Next, a 2.75 x 15 mm Xience Xpedition stent was deployed 
over the target lesion at 12 atmospheres. Stent balloon was reinflated 
again to 18 atmospheres. Stent was then postdilated with a 3.0 x 12 mm 
NC balloon with multiple inflations from 16-24 atmospheres. Next 
intracoronary nitroglycerin was given and a final angiographic images of 
the right coronary artery were obtained showing no residual stenosis and 
a mild step-up and step-down at the stent. The coronary wire was then 
removed and the guide catheter was now used to engage the saphenous vein 
graft to the diagonal branch. The BMW wire was now advanced past the 
tight 90% stenosis just distal to the anastomotic site at the D1. 
Angioplasty of the lesion was now done with 2.0 x 10 mm balloon with 
multiple inflations to 10 atmospheres. The balloon, however, was 
slipping each time. The balloon was then exchanged for a 2.0 x 10 mm 
AngioSculpt balloon, which was used to successfully perform angioplasty 
at 10 atmospheres. Angiographic images of the saphenous vein graft was 
then obtained after administering intracoronary nitroglycerin. A 2.5 x 
15 mm Xience Xpedition stent was then deployed at the target site from distal 
SVG into the diagonal at 10 atmospheres. The stent was post-dilated with 
2.5 x 12 mm NC balloon with multiple inflations from 14-18 atmospheres. 
Balloon was removed and angiography images were acquired. 
The wire was then removed and final 
angiographic images were acquired showing no residual stenosis. 
The guide catheter was now removed over a wire. Right femoral 
angiography was then done. The femoral sheath was then secured in 
position for subsequent removal.The patient was then transferred to 
the recovery unit with stable vitals and preserved lower extremity pulse. 
ESTIMATED BLOOD LOSS: 
About 30 mL. 
TOTAL FLUOROSCOPY TIME: 
20.3 minutes. 
FLUOROSCOPY DOSE: 
220,224 mGycmsq. 
TOTAL CONTRAST: 
325 mL of Isovue. 
HEMODYNAMICS: 
Aortic pressure was 136/66. LV systolic pressure was 136 with 
end-diastolic pressure of 23. There was no gradient between the left 
ventricle and the aorta. 
LV ANGIOGRAPHY: 
LV gram shows a normal sized LV with ejection fraction of 45%. There is 
mid to distal anterolateral and basal to mid inferior hypokinesis. 
THORACIC AORTOGRAPHY: 
Thoracic aortography shows a normal size aorta without any aortic 
regurgitation. 
A single graft is seen going to the first diagonal. 
CORONARY ANGIOGRAPHY: 
Left Main Coronary Artery: The left main coronary artery is a medium to 
large vessel which ends by bifurcating into LAD and left circumflex 
coronary arteries. No lesions are noted in the left main coronary 
artery. 
Left Anterior Descending Coronary: This is a medium size vessel which 
is completely occluded proximally at the bifurcation of the first 
diagonal. The first diagonal is seen proximally as a wispy vessel with 
multiple stenotic areas from 70-90%. Diagonal graft is seen in the 
proximal diagonal with 90% stenosis just distal to the anastomosis of 
the graft. 
Left Circumflex Coronary Artery: The left circumflex coronary artery is 
a medium to large vessel which gives rise to 3 obtuse marginal branches 
then continues into the AV groove at the end of a posterolateral branch. 
The first and third branches are medium to small vessels without any 
lesions. The second obtuse marginal is a large vessel and without any 
significant lesions. The distal circumflex is of small caliber with 
some haziness along its course. 
Right Coronary Artery: The right coronary artery is a medium to large 
vessel and is dominant. It gives rise to a PDA and PL branches. There 
is severe 99% stenosis in the proximal to mid right coronary artery with 
TIMI 2 flow distally. 
Saphenous vein graft angiography shows vein graft supplying the first 
diagonal branch. There is antegrade filling of the D1 and retrograde 
filling of the circumflex and the left main. There is a severe stenosis 
off the first diagonal just distal to the anastomosis with 90% stenosis. 
Proximal to the anastomosis there is a long segment of stenosis varying 
from 70-90%. 
LIMA angiography shows a mature LIMA graft anastomosing to the mid LAD. 
The LAD is of small caliber, which is occluded proximally. 
Post-PCI there was no residual stenosis in the mid right coronary and 
TIMI-3 flow was noted distally. 
Post-PCI of the diagonal lesion there was no residual stenosis at the 
target site and TIMI-3 flow was noted from the graft with antegrade flow into 
First diagonal branch. Retrograde flow from the graft into the proximal diagonal, 
back into the left main was substantially reduced following the 
intervention. 
CONCLUSION: 
1. Status post successful PCI/stent of severe proximal mid right 
coronary and severe proximal first diagonal stenosis. 
2. Mildly reduced LV (left ventricular) systolic function. 

Thank You


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## cgbar (Apr 19, 2014)

Appears you left off the stenting of the D1 through the SVG. Code 92937

Well written report!

Glenn


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## rparikh (Apr 20, 2014)

Thank you


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