# LHC and Cerebral/Selective Carotid Angio



## AshleyMartin (Feb 7, 2011)

Please help me code this:

Procedure Performed:
1. Left heart catheterization with selective coronary angiography
2. LV gram
3. Cerebral/selective carotid angiography

Indications: The patient is a 64 y/o male with prior history of coronary artery disease. status post PTCA remotely presenting with possible TIA with left sided arm and leg weakness that is now resolved. The patient had a troponin draw that was mildly elevated at .24. The patient was offered coronary angiography for evaluation of his anatomy. The patient as well was incidentally found to have possible left middle cerebral artery aneurysm. 

PROCEDURE IN DETAIL:
After informed consent was obtained, the patient was brought into the Cath Lab and placed on the table. The patient was prepped and draped in the usual sterile fashion. Access was obtained bu the right femoral artery via a modified Seldinger technique after 1% lidocaine was used to anesthetize the area. Initially we used a Benson wire and a JL-4 diagnostic cathether to cross the tortuosity in the right iliac. We then placed a long 23 cm sheath. Initially we attempted to cannulate the right coronary artery using the JR-4 catheter. This was unsuccessful. Anomalous takeoff was visualized. We then used an AL-1 diagnostic catheter, There was a high takeoff anteriorly of a right coronary artery. This was selectively engaged. The right coronary artery was studied. It was exchanged for a JL-4. This was used to selectively engage the left main artery. A significant lesion of the left main was noted. We upgraded to a JL-5 diagnostic catheter. This was used to selectively engage the left main artery. The left coronary system was studied. The pigtail catheter was then exchanged over the wire. This was introduced into the left ventricle across the aortic valve. Hemodynamic measurements were taken. LV gram was performed. The catheter was then withdrawn across the aortic valve to measure for any significant gradient. We then performed selective carotid, as well as cerebral angiography using s 4 French Berenstein 2 catheter. We were able to selectively engage each of the common carotids using a guide wire. A selective angiographic shot of the right femoral access site was then taken. There was a high bifurcation. The sheath was pulled and manual pressure was applied to obtain hemostasis. The patient tolerated the procedure well. There were no complications. 

FINDINGS:
1. Left main; there is a distal lesion involving the left anterior descending and left circumflex bifurcation. 
2. Left anterior descending has a calcified ostial 90% lesion. The vessel is diffusely diseased distally. 
3. Left circumflex has an ostial 80% lesion.
4. Right coronary artery; there is a high anterior anomalous takeoff. It is occluded in the mid portion of the vessel and it fills distally by left to right collaterals. 
5. LV ejection fraction is 55%. EDP is 14mm of Mercury. 
6. Left internal carotid artery and external carotid artery are patent. Internal carotid artery fills the MCA, as well as the ACA. In the proximal portion of the left middle cerebral artery, there is a significant atherosclerotic stenosis with post stenotic dilatation.
7. The right internal carotid artery/external carotid artery are patent. The internal carotid artery fills via middle cerebral artery, as well as the anterior cerebral artery. The right internal carotid artery has a mild ulcerated plaque.

DIAGNOSES:
1. Significant multivessel coronary artery disease.
2. Significant intracerebral atherosclerosis.
3. Normal LV systolic function.


I have: 
93458-26
75671
75680


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## Jim Pawloski (Feb 7, 2011)

AshleyMartin said:


> Please help me code this:
> 
> Procedure Performed:
> 1. Left heart catheterization with selective coronary angiography
> ...



Assuming normal anatomy, add 36216-rt and 36215-lt-59.  Add -59 to the cerebral portion of the study. (75671-59 and 75680-59)
HTH,
Jim Pawloski, CIRCC


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## AshleyMartin (Feb 8, 2011)

Thank you! I am not used to coding carotid and cerebral angiograms so this one really had me questioning myself.


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