# Overlapping Stents in different vessels



## annamarie1623 (Jan 12, 2016)

I know that we only bill for one stent if they are overlapping in the same vessel but can you bill for the 2 different vessels if they are overlapping?  Op note below, please advise!  Thank you! 






PROCEDURE:

1. Left heart catheterization.

2. Coronary angiography.

3. Successful percutaneous coronary intervention of 95% ostial left main

   disease with a 4.0 x 16 mm Promus Premier drug-eluting stent to a 0%

   residual stenosis.

4. Successful percutaneous coronary intervention of 75% ostial circumflex

   disease with a 3.5 x 16 mm Promus Premier drug-eluting stent with 0%

   residual stenosis.

5. Successful insertion of Impella CP percutaneous heart assist device.

6. Right heart catheterization.

7. Emergent intraaortic balloon pump insertion.

8. Intravascular ultrasound left main post stenting.

9. Intravascular ultrasound left circumflex post stenting.



INDICATIONS: ... is a delightful, 62-year-old, African American

female who underwent coronary angiography by myself 48 hours ago, which

noted critical left main, as well as ostial LAD disease.  She was taken

emergently to the operating room by Dr. ...., where she underwent

emergency 2 vessel CABG with saphenous vein graft to the obtuse marginal

branch vessel and saphenous vein graft to the LAD.  Earlier this morning,

the patient had a cardiac arrest in the cardiac intensive care unit.  Dr....

 was alerted and emergency consultation was requested for emergent

coronary angiography for definitive delineation of coronary anatomy.



PROCEDURE CONSENT: Implied consent was utilized in the setting of an

emergency.



TOTAL FLUOROSCOPIC TIME: Is 17.1 minutes (1.0 Gy.)



TOTAL VISIPAQUE USED: 150 mL.



TOTAL SEDATION: None.



PROCEDURE NOTE: The patient was brought to the cardiac catheterization lab

where she was identified as .....  She was placed in supine

position on the cardiac catheterization table and prepped and draped in the

usual sterile fashion.  Using tactile stimulation, fluoroscopic guidance,

as well as modified Seldinger technique, the left common femoral artery was

accessed without any difficulty with a 4 French stiff micropuncture.  A 6

French sheath was introduced into the left common femoral artery.



For right heart catheterization, using the venous access, an 8 French

Swan-Ganz catheter, with the balloon tip inflated, was advanced to the

level of the right atrium, right ventricle, pulmonary artery and pulmonary

capillary wedge position.  Hemodynamic and oxygen saturation were completed

in all chambers.  The catheter was maintained in place.  Using the left

common femoral arterial access over 0.035 J-wire, a 6 French JL4 catheter

was used to selectively engage the left coronary system.  Multiple

angiographic views were obtained.  Over a 0.035 J-wire, a 6 French JR4

catheter was introduced into the left ventricular cavity for left heart

catheterization.  No left ventriculogram was completed.  Catheter was

pulled back across the aortic valve for evaluation of gradient.  A 6 French

JL4 catheter was used to selectively engage the right coronary system as

well as both saphenous vein grafts and multiple angiographic views were

obtained.  At the conclusion of the study, the catheter was removed over a

0.035 J-wire and the J-wire removed.



PROCEDURE FINDINGS: (HEMODYNAMIC DATA)

1. Aortic pressure 70/35 mmHg.

2. LV systolic pressure is 90 mmHg.

3. LVEDP is 20 mmHg.

4. On catheter pullback across the aortic valve, there was no gradient.

(ANGIOGRAPHIC DATA)

1. Left main:  Unchanged angiographic appearance with 75% ostial disease

   with extensive catheter dampening.

2. Left anterior descending: 100% occluded in its mid segment and fills by

   way of the vein graft.

3. Left circumflex:  70% ostial disease in a large caliber dominant system,

   which gives rise to the obtuse marginal branch vessels, as well as all

   posterolateral branches and the left posterior descending artery.  There

   is an intermediate caliber ramus intermedius, which is with ostial

   disease.

4. Right coronary artery:  Small, nondominant vessel.



VEIN GRAFT ANGIOGRAPHY:

1. Saphenous vein graft to the obtuse marginal branch vessel: 100% occluded

   in its proximal segment.

2. Saphenous vein graft to the LAD:  Widely patent graft with no apparent

   stenosis noted at the anastomotic site.  There is retrograde filling of

   the LAD.

This concludes the angiographic portion of the study.  Upon review of

baseline patient presentation, as well as angiographic data, and

discussions with our CT surgical team, Dr. ...., we elected to proceed

with emergent angioplasty and PCI to the left main, in the setting of

profound cardiogenic shock with graft closure.  In light of the patient's

hemodynamic instability, intraaortic balloon pump was required.



CORONARY INTERVENTION: The patient had suspicion for HIT positive and as

such she was given Angiomax intravenous bolus, as well as Angiomax drip for

the duration of the study.



Under strict sterile conditions, the left common femoral artery sheath was

exchanged under fluoroscopic guidance for a balloon pump sheath. A 34 CC

intraaortic balloon pump is advanced just distal to the left subclavian and

the intraaortic balloon pump counterpulsation was initiated at 1:1.  There

was confirmation of adequate distal perfusion by pulse oximetry of the left

radial artery.  At this point, with hemodynamic stability, using tactile

stimulation, fluoroscopic guidance, as well as modified Seldinger

technique, the right common femoral artery was accessed without any

difficulty with a 4 French stiff micropuncture sheath.  A 6 French sheath

was introduced into the right common femoral artery.  Over a 0.035 J-wire,

a 6 French JL4 guide catheter with side holes was used to selectively

engage the left coronary system. A BMW universal wire was advanced to the

distal circumflex.  A 2.0 x 12 mm Emerge balloon was used to predilate the

stenotic segment. A 4.0 x 16 Promus Premier drug-eluting stent was

successfully deployed in the ostium of the left main.  Distal to this, in

an overlapping fashion, a 3.5 x 16 mm Promus Premier drug-eluting stent was

successfully deployed at the ostium of the circumflex.  The stents were

post dilated with a 4.5 x 8 mm NC Quantum.  IVUS catheter was used, which

confirmed excellent stent apposition with excellent stent deployment.  No

dissection or thrombus burden.  The guide wire was removed.  TIMI-3 flow

preprocedure and post procedure.  The guide catheter was removed over the

0.035 J-wire and the J-wire removed.  At this point, the patient continued

to have significant hemodynamic compromise and, as such, we elected to

proceed with insertion of Impella CP.



The right common femoral artery access was exchanged under strict sterile

conditions for an Impella sheath.  Measurement of cardiac sampling and

pressure, right heart percutaneous approach was completed.  Plain

radiography of multiple coronary arteries using high osmolar contrast was

completed.  Assistance with cardiac output using Impella pump, continuous,

was initiated.  The Impella pump sheath was secured as was the balloon pump

sheath in addition to the Swan-Ganz sheath.



The patient was transferred to the cardiac intensive care unit in critical

condition.



PROCEDURE:

1. Assistance with cardiac output using Impella pump, continuous.

2. Measurement of cardiac sampling and pressure, right heart percutaneous.

3. Plain radiography of multiple coronary arteries using high osmolar

   contrast.

4. Left heart catheterization.

5. Successful percutaneous coronary intervention of 75% ostial left main

   disease with a 4 x 16 mm Promus Premier drug-eluting stent to a 0%

   residual stenosis.

6. Successful percutaneous coronary intervention of 75% ostial circumflex

   with a 3.5 x 16 mm Promus Premier drug-eluting stent to a 0% residual

   stenosis.

7. Intravascular ultrasound of the stented segments.

8. Emergent placement of intraaortic balloon pump.

9. Emergent Swan-Ganz catheter placement.



PROCEDURE FINDINGS RIGHT HEART DATA: OXYGEN SATURATIONS

1. Femoral artery is 92%.

2. Pulmonary artery is 38%.

3. Right atrium is 46%.

PRESSURES

1. Right atrium is 26%.

2. Pulmonary artery is 39/25 mmHg.

3. Mean pulmonary artery is 30 mmHg.

4. Pulmonary capillary wedge pressure is 25 mmHg.

FICK CARDIAC OUTPUT:  3.66 L/min.



FICK CARDIAC INDEX:  2.01 L/min per meter squared.


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## heart123 (Jan 16, 2016)

I believe only one they are both in the LC


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