# Selective Angiography



## OPENSHAW (Mar 7, 2014)

Diagnostic Coronary Angiogram

Pre-Procedure Diagnosis: dizziness with + carotid duplex, angina with positive Nuclear stress
Post-Procedure Diagnosis: Left internal carotid stenosis, CAD

Procedure performed:  
Selective angiography of Left Main coronary artery
Selective angiography of right coronary artery
LHC without LV gram
Selective angiography of right carotid artery
Selective angiography of left carotid artery
Thoracic aortic arch angiogram

Anesthesia Used: IV versed and fentanyl, local 2% lidocaine

Blood Loss: 40 mL

Condition: stable

IV Contrast Used:  230 mL

Complications: none

Procedure and Findings in Detail: The procedure was described to the patient including benefits, risks, and alternatives to the procedure.  The patient confirmed understanding.  The patient signed the informed consent.  He was brought into the cath lab.  The bilateral groins were prepped in a sterile fashion, and a sterile drape was placed over the patient.

The right common femoral artery (CFA) was palpated and the region above the artery was anesthetized with 2% local lidocaine.  A Cook needle was used to access the right CFA.  The wire was visualized under fluoroscopy ascending into the common iliac artery.  A 6 French sheath was placed over the wire without difficulty in the normal form and fashion.

A 6 Fr diagnostic JL4 was placed in the ascending aorta directed by a J wire.  The J wire was removed, the catheter aspirated to remove any air and flushed with normal saline.  The diagnostic catheter engaged the left main without difficulty.  The diagnostic evaluation revealed the following: 
Left main: diffuse with focal 40-50% stenosis 
LAD: diffuse disease with significant distal disease
Diagonals: diffuse non obstructive disease
Circumflex: proximal disease and aneurysmal changes with a number of OMS, diffuse disease

The diagnostic catheter used for the left coronary was removed from the descending aorta over the J wire.  A 6 Ft diagnostic JR4 was placed over the wire and guided to the ascending aorta.  The J wire was removed.  The catheter was aspirated and flushed with normal saline.  The diagnostic evaluation revealed the following: 
RCA: small vessel, dual dominant mid 60-70% lesions

The RCA catheter was removed from the descending aorta over a J wire. We then advanced a 5French pigtail catheter into the LV to obtain LVEDP and LV pressures. There was no gradient on pull back. 

We then removed the pigtail over a J wire and exchanged again to the RCA catheter. We were easily able to cannulate the left carotid and performed selective angiography. We noted 95% proximal stenosis of the internal carotid.

We then attempted to engage the right carotid however had difficulty engaging the right subclavian. We attempted to use multiple catheters including the RCA cath, an AR1, 5french headhunter as well 5french VTK. We were able to engage the difficult angulation and advance both a wooly wire and glide wire but were unable to advance the catheters further due to the angulation. Given this we attempted angiography and felt we were initially in the vertebral given a lack of bifurcation seen. We then exchanged the VTK for the pig tail and did a arch nonselective angiogram and this revealed that we were infact in the carotid and that the external carotid was in the same plane as the internal and we were unable to clearly see it. 
Right internal carotid 40-50% prox stenosis

The patient was in hemodynamically stable condition throughout entirety of the procedure.  The sheath was removed and manual pressure was held for 20 mins., and the patient will be on bed rest for 6 hours.  Aggressive medical management for CAD and associated risk factors will continue and there are no changes to the medications.  Patient will have labs redrawn in 2 days to check a basic. Aggressive hydration was continued in the holding area and during bedrest for reno protection.

Summary:
Nonobstructive diffuse CAD
Right internal carotid artery stenosis of 40-50%
Left internal carotid artery stenosis of 95%. Will discuss surgical vs PCI options with patient given renal risk. 

Meds: Start coreg and crestor

Would this be coded as:
93458-26, dx. 414.00, 794.30
93567, dx. 414.00, 794.30
36222-50, dx. 447.1
36226, dx 447.1
Code 36225 bundles.

Thank you!


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## Jim Pawloski (Mar 7, 2014)

OPENSHAW said:


> Diagnostic Coronary Angiogram
> 
> Pre-Procedure Diagnosis: dizziness with + carotid duplex, angina with positive Nuclear stress
> Post-Procedure Diagnosis: Left internal carotid stenosis, CAD
> ...



I would not bill the 93567 as the arch study was done, not the aortic root.  I would also not bill 36226, because there is no findings of the vertebral arteries.
HTH,
Jim Pawloski, R.T.(R)(CV), CIRCC


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