# need help with carotid and celebral angio



## bhargavi (Apr 9, 2015)

INDICATIONS                                                                     
History of cerebrovascular accident progressive stenosis right internal carotid 
artery by duplex imaging, history of left carotid stenting.

PROCEDURE                                                                       
Diagnostic aortic arch cerebral angiogram followed by innominate and right 
subclavian digital subtraction angiogram, followed by right carotid selective 
angiogram and right cerebral angiogram, followed by left subclavian angiogram, 
followed by left common carotid selective digital subtraction angiogram, 
followed by left cerebral angiogram, followed by right ileofemoral angiogram.

DESCRIPTION OF PROCEDURE                                                        
After obtaining informed consent from the patient, a five French sheath was 
placed in the right common femoral artery.  A five French pigtail catheter was 
advanced into the aortic arch and aortic arch cervical cerebral digital 
subtraction angiogram was performed.  This catheter was then exchanged out for 
a five French diagnostic Judkins right coronary catheter.  This was used 
utilized for advancement of the catheter into the innominate artery for 
selective innominate and right subclavian digital subtraction angiogram.  Under 
fluoroscopic guidance and with the use of a hydrophilic Zip wire, this catheter 
was then advanced selectively into the right common carotid artery proximal to 
mid vessel.  The right common carotid artery selective digital subtraction 
angiogram was performed of the cervical segment and additionally selective 
right cerebral angiogram was performed in the anterior, posterior and lateral 
projections.  The catheter was then removed and advanced into the left 
subclavian artery. The left subclavian selective digital subtraction angiogram 
was performed.  This catheter was then exchanged out for a five French Vitek 
catheter which was utilized to selectively engage the left common carotid 
artery vessel.  Selective left common carotid artery digital subtraction 
angiogram of the cervical segment was then performed, followed by selective 
left cerebral angiogram performed in the anterior posterior and lateral 
projections.  The Vitek catheter was removed and angiography through the sheath 
revealed the sheath in the common femoral artery and closure was obtained with 
manual compression.  No closure device was utilized.  There were no 
complications.

HEMODYNAMICS                                                                    
The intraaortic pressure was 115/60.                                            
The aortic arch was patent with mild calcification and plaque on the superior 
aspect. The patient had a Type I aortic arch essentially.
The innominate and right subclavian as well as right vertebral were patent.  
There was minimal calcification or tortuosity of the innominate and right 
common carotid artery. The right common carotid artery was patent, however, at 
the bifurcation, the internal carotid artery on the right was widely patent.  
However, there was severe stenosis of 80 to 90 percent at the osteal segment of 
the right internal carotid artery. Beyond this, there was moderate tortuosity 
of the vessel although it was widely patent into the cerebral vessels.  The 
right middle cerebral artery filled briskly although there was evidence for 
collateral dilution of the contrast and there was, in fact, no filling of the 
right anterior cerebral artery or any right to left crossover filling.  There 
was no notable stenoses of the right intracerebral vessels.  The left 
subclavian was patent with less than 30 percent stenosis and tortuosity in the 
proximal but nonosteal segment.  The left internal mammary artery in the left 
vertebral were, otherwise, patent.  The left common carotid artery arose in a 
normal fashion between the innominate and left subclavian with mild plaque at 
the ostium.  This vessel was best engaged with the Vitek catheter as noted.  
This vessel was widely patent. There was a stent present in the proximal 
segment of the left internal carotid artery which had some mild band or kinking 
but was widely patent.  The left external carotid artery was also patent.  The 
continuation of the left internal carotid artery into the cerebral vessels was 
widely patent and there was very prominent filling of the right anterior 
cerebral artery and right intracerebral vessels from left to right crossover 
filling through the left internal carotid artery and its distal vessels.

SUMMARY AND CONCLUSIONS                                                         
1.  Severe stenosis of osteal segment of the right internal carotid artery.     
2.  Widely patent left internal carotid artery stent placed in 2007.            
3.  Significant left to right collateral filling crossover from left cerebral 
vessels to the right cerebral vessels primarily through the anterior 
communicating artery and anterior cerebral vessel.

RECOMMENDATIONS                                                                 
The patient will be continued on his antiplatelet regimen as well as medical 
management and be considered for intervention of his right internal carotid 
artery stenosis.

        i am thinking of 36222,36225 since 36221 is bundled into 36222
i would really appreciate if anyone can help. i am cath lab coder in hospital


----------



## Chlrtrep (Apr 9, 2015)

For carotids I would use CPT Code 36223 as both intracranial(cerebral)and extracranial(cervical) carotids were imaged and reported. -50 for bilateral.

36223-50

CPT code 36225 I am not sure.  I am not sure if the vertebrals are being commented on from the cerviothoraic arch angio or from the selective subclavian images


----------



## bhargavi (Apr 10, 2015)

thank you soooo much fo r help


----------

