# Unsuccessful attempt at stenting of the left carotid artery



## jlb102780 (Oct 9, 2009)

Here's a copy of the report, I know its pretty long. But very detailed. Any help on coding this would be great. I've not come across an Unsuccessful procedure before. Thanks 

Jammie Mack, CPC



                          CARDIOLOGY SERVICES REPORT                          

DATE OF TEST:  10/08/2009                                                     

NAME OF PROCEDURE                                                             
Left carotid stent.                                                           

HISTORY                                                                       
The patient is a very pleasant unfortunate 88-year-old female who has had     
recurrent symptoms of TIA.  She has a carotid angiogram performed at Memorial 
Medical Center a couple of months ago and was found to have an ulcerated 60   
to 70% plaquing in her left internal carotid artery.  She was set up to have  
a carotid stent placed over there in a couple of weeks.  The patient has      
multiple medical problems including severe coronary artery disease as well as 
reduced left ventricular systolic function.  She is admitted over here to     
Baptist Medical Center.  Dr. Schimmel, her regular cardiologist consulted me  
and asked me to try to place a carotid stent.  I reviewed her films carefully 
from her angiogram at Memorial Medical Center a couple of months ago.  She    
was noted to have a bovine aortic arch with relatively small carotid arteries.

The patient also has significant renal insufficiency.  She was started on     
Mucomyst and was given intravenous fluids.  She has been followed by the      
renal service as well.                                                        

PROCEDURE                                                                     
The patient was brought to the cardiac cath lab in relatively stable          
condition.  She was placed on the cath lab stretcher.  She was prepped and    
draped in the usual sterile fashion.  She was having some complaints of right 
and left hip pain from arthritis.  Laying on the cardiac cath lab table was   
very uncomfortable for her.  We decided to sedate her slightly.  She was      
given 50 micrograms of intravenous fentanyl and 25 mg of intravenous          
Benadryl.  This worked very nicely to sedate her for the procedure.  She was  
very stable.  She was arousable during the procedure, however.                

The right groin area was prepped and draped in the usual sterile fashion.     
Using 1% Xylocaine, the right femoral area was anesthetized.  Using a Cook    
needle, the right femoral artery was entered without difficulty and a 6       
French sheath was inserted via Seldinger technique. The sheath was aspirated  
and flushed.  A 4 French glide catheter was then carefully advanced over a J  
wire up into the patient's ascending aorta.  We were unable to manipulate the 
4 French angled Glide catheter into the patient's left carotid artery.  We    
subsequently switched out over a J wire for a 4 French HN5 diagnostic         
catheter.  This diagnostic catheter was successfully manipulated into the     
proximal aspect of the patient's left common carotid artery.  An angled Glide 
wire was manipulated up into the patient's left internal carotid artery.  We  
then carefully switched out for a 4 French angled Glide catheter.  This Glide 
catheter was advanced up over the Glide wire up into the patient's left       
common carotid artery.  The Glide wire was then removed.  We performed a      
cineangiogram utilizing digital subtraction angiography in LAO projection and 
documented the patient did have a 70% or so lesion in her left internal       
carotid artery.  Her left common carotid artery and her left internal carotid 
artery were relatively small vessels.  The left external carotid artery was a 
very small vessel.                                                            

I then was able to manipulate the Glide wire up into the patient's left       
external carotid artery.  We placed a Glide catheter up into the patient's    
left external carotid artery.  We then removed the Glide wire.  We switched   
out for a Supra Core wire which is a 0.035 inch wire.  The tip of the wire    
was very floppy but the rest of the wire was very stiff in order to deliver a 
sheath.  Unfortunately, we tried to place this exchange wire up into the      
patient's left carotid artery, a Multipurpose catheter would not support      
this.  The Multipurpose catheter prolapsed down into the aorta.               

We removed the Multipurpose catheter with a conventional J wire.  The patient 
had been given 5,000 units of intravenous heparin once we successfully        
cannulated the left carotid artery with the HN5 catheter.  We placed the 4    
French HN5 catheter back into the patient's left carotid artery.  I again     
manipulated the angled Glide wire up into the patient's left internal carotid 
artery.  I then switched out carefully for a 5 French vertebral catheter.     
This catheter was manipulated over the Glide wire up into the patient's left  
common carotid artery.  I then carefully was able to successfully advance the 
0.035 inch Supra Core exchange wire up into the distal aspect of the          
patient's left common carotid artery.  My plan was to just try to get a       
sheath to go into the proximal aspect of the left common carotid artery.  We  
removed the vertebral catheter.  We then removed the short sheath.  We        
attempted to bring up a 6 French Cook shuttle sheath as this is a standard    
sheath used for carotid stenting.  Unfortunately this sheath would not take   
the turn and enter the patient's left common carotid artery.  The patient     
does have a bovine arch with left common carotid artery arising directly off  
of the brachiocephalic artery.  The Supra Core wire prolapsed down to the     
aorta during this time.  I then switched back out over a conventional J wire  
for a conventional short 6 French sheath in the right femoral artery.         

I reviewed the patient's situation carefully.  It was very obvious that we    
would not be able to get a 6 French sheath up to negotiate her proximal       
aspect of her left common carotid artery due to the fact that she has a       
bovine aortic arch.  The other option would have been to try with an 8 French 
sheath and use a guiding catheter.  I felt that the patient had a very small  
left common carotid artery as well as a very small left internal carotid      
artery.  I did not feel that utilizing an 8 French guiding catheter was a     
wise decision. The procedure was therefore terminated.                        

The patient was very stable at the conclusion of the procedure.  An ACT was   
obtained and was noted to be 215 seconds.  Her sheaths will be removed        
eventually when her ACT comes down to a target level.  She was very arousable 
at the conclusion of the case and there was no change in her neurologic       
status.                                                                       

It should also be noted that since we performed only one cineangiogram with   
contrast, the patient received a total of only 10 mL of dye for the procedure.

CONCLUSION                                                                    
Unsuccessful attempt at stenting of the left carotid artery.  We were unable  
to successfully manipulate a 6 French shuttle sheath into the left common     
carotid artery over a stiff wire despite the couple attempts to do so.  Since 
the patient has a very small left common carotid artery, I felt that trying   
to perform the procedure with an 8 French guiding catheter would be           
potentially very dangerous.  This was therefore not attempted.


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## dpeoples (Oct 9, 2009)

jlb102780 said:


> Here's a copy of the report, I know its pretty long. But very detailed. Any help on coding this would be great. I've not come across an Unsuccessful procedure before. Thanks
> 
> Jammie Mack, CPC
> 
> ...



I could make a case for 37215-53 but would instead just code what was actually performed, another angiography. This is because the stent was never unpacked or attempted to be placed.

36217/75676/75665 (left internal carotid is a third order vessel when a bovine arch is present).

HTH


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## jlb102780 (Oct 13, 2009)

Thanks so much for your help Danny


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