karbaker
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Need helping coding, just getting more and more confused.thanks
NAME OF PROCEDURE:
1. Arch aortography.
2. Bilateral carotid angiography.
INDICATION FOR PROCEDURE: Patient with suspected carotid stenosis
DESCRIPTION OF PROCEDURE: After proper explanation of the procedure, its indications, risks and benefits, an informed consent was obtained from Mr and he was taken to the cath lab in fasting state. The patient was prepped and draped in the usual sterile fashion. IV conscious sedation was induced using cath lab protocol. Right groin area was prepped and draped in the usual sterile fashion. It was infiltrated with approximately 10 ml of 1% lidocaine and satisfactory local anesthesia was achieved. Right femoral artery was cannulated using an 18 gauge needle and a 5 French arterial sheath was placed. Sheath was flushed.
A 5 French pigtail catheter was then advanced through the arterial sheath and placed in the aortic arch. Arch aortography was performed and thereafter bilateral selective carotid angiography was performed with a JB2 catheter. At the end of angiography the catheter was removed, sheath was flushed and findings were reviewed. The patient did well.
ARCH AORTOGRAPHY: This study demonstrated normal contour, course and caliber of aortic arch. Origins of the right brachiocephalic, left common carotid and left subclavian were visualized and there was no stenosis at the origins of these vessels.
BILATERAL CAROTID ANGIOGRAPHY:
1. Selective angiography of the right carotid artery demonstrated normal contour, course and caliber of
right brachiocephalic and right common carotid. At the origin of the right internal carotid there was a
moderate calcified plaque. This was not now-limiting. Right external carotid was occluded.
2. Selective angiography of the left carotid artery demonstrated normal contour, course and caliber of the
left carotid artery. Minimal plaque was visualized at the origin of the left internal carotid artery. Carotid
endarterectomy site was patent.
CONCLUSION: In summary the patient demonstrates moderate disease a1 the origin of the right carotid artery and minimal plaque in the left internal carotid artery origin.
DISCUSSION &. RECOMMENDATIONS: After carefully reviewing these findings we recommend continued medical management and risk factor modification.