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NOT SURE OF THE PROPER CODES, THIS IS FOR MEDICARE PART B
THANKS! After obtaining informed consent, the patient was
transported in the nonsedated condition to the cardiac
catheterization suite. The patient was prepped and draped in a
sterile fashion. Lidocaine 2% was used to infiltrate the skin and
subcutaneous tissue overlying the right common femoral artery. A
#6 French introducer sheath was placed in the right common femoral
artery utilizing the modified Seldinger technique. I then used a
#6 French multipurpose catheter to cross the aortic valve measured
end-diastolic pressures and performed ventriculography. The
multipurpose catheter was withdrawn across the aortic valve and
used for radial graft angiography and saphenous vein angiography.
I used a mammary catheter for left internal mammary angiography
and native right coronary angiography. A JL-4 catheter was used
for left coronary angiography. I then proceeded with the
intervention as described below.
FINDINGS:
HEMODYNAMICS: LV pressure was 160/13. Aortic pressure 160/83.
RAO LEFT VENTRICULOGRAM: Ventriculography demonstrates left
ventricular systolic function that is well preserved. The
estimated ejection fraction is 50-55%. It is unchanged from prior
to bypass surgery.
CORONARY ANGIOGRAPHY:
LEFT MAIN CORONARY ARTERY: Originates from the left coronary
cusp. It trifurcates into the left anterior descending artery,
ramus intermedius and left circumflex artery. The left main
coronary artery is moderately calcified and severely diseased. At
its origin, is an eccentric 50% plaque. In the distal third of
the left main, at its trifurcation there is a 60-70% stenosis.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left anterior
descending artery is severely diseased throughout its length. It
gives rise to a first diagonal vessel very proximally. This is a
1.5 to 2.0 mm vessel in diameter. It has a tubular 70% stenosis
proximally and a tubular 80% distally. After the first diagonal
vessel, the left anterior descending artery has diffuse 50-70%
stenosis and then is occluded.
RAMUS INTERMEDIUS: The ramus intermedius is a large branching
vessel. It is diffusely diseased. There are sequential 70%
stenoses through its proximal and its mid segments. This was
followed by an 80% stenosis. There is competitive flow distally.
LEFT CIRCUMFLEX CORONARY ARTERY: The left circumflex artery is
occluded at its origin.
RIGHT CORONARY ARTERY: Originates from the right coronary cusp.
It is an anatomically dominant vessel. It is diffusely diseased.
Throughout its mid segment is an eccentric 50% plaquing. The mid
right coronary artery gives rise to an RV marginal branch that
supplies right-to-left collaterals to the apical LAD. That RV
marginal branch has a 90% stenosis. The posterior descending
artery is occluded and fills via left-to-right collaterals. The
posterolateral branch is diffusely diseased and gives off several
small less than 1.0 mm branches. There are right-to-left
collaterals to the occluded distal circumflex.
There is a radial graft to the distal circumflex's obtuse marginal
branch. That vessel is patent.
There is a saphenous vein graft to the ramus intermedius called
OM1 in the surgeon's report. That graft is severely diseased
through its proximal and mid segment with a long tubular 90%
stenosis and TIMI-1 flow.
The free radial graft to the LAD is patent, however, immediately
distal to the anastomosis, there is a new 90% stenosis in the LAD.
This is then followed by diffuse 90% and 95% stenosis in the
distal to transapical segment of the LAD.
INTERVENTION: Based on findings at diagnostic catheterization, we
proceeded with intervention on the vein graft to the ramus
intermedius. Angiomax was administered and a BMW Elite wire was
advanced into the target vessel. A 2.5 x 20 mm balloon was used
to dilate the diseased segment of the proximal to mid saphenous
vein graft. I then positioned a 3.0 x 30 mm Integrity Resolute
stent and deployed it with two inflations up to 12 atmospheres. In
the ostial proximal segment of the graft, I deployed a 2.75 x 14
mm Resolute stent. I then returned with a 3.0 x 30 mm balloon to
the 2.75 mm stent and post deployed it with inflations up to 18
atmospheres. After removal of my balloons and wires, there was
TIMI-3 flow with no perforation, dissection or distal
embolization.
I then turned my attention to the radial graft to the LAD. The
same BMW Elite wire was advanced into the distal LAD. I tried to
advance a 1.5 x 10 mm Sprinter balloon but would not cross through
all the most distal diseased segments of the LAD and I decided to
limit treatment to the new immediate post anastomosis stenosis. I
ballooned this and then deployed a 2.25 x 12 mm Integrity Resolute
at six atmospheres. I removed the stent delivery balloon and then
returned with a 2.25 x 8 mm NC balloon and performed angioplasty
to 12 atmospheres within the stent to ensure there was no
dissection of this very small calcified vessel. After removal of
balloons and wires, we had TIMI-3 flow with no perforation,
dissection or distal embolization.
THANKS! After obtaining informed consent, the patient was
transported in the nonsedated condition to the cardiac
catheterization suite. The patient was prepped and draped in a
sterile fashion. Lidocaine 2% was used to infiltrate the skin and
subcutaneous tissue overlying the right common femoral artery. A
#6 French introducer sheath was placed in the right common femoral
artery utilizing the modified Seldinger technique. I then used a
#6 French multipurpose catheter to cross the aortic valve measured
end-diastolic pressures and performed ventriculography. The
multipurpose catheter was withdrawn across the aortic valve and
used for radial graft angiography and saphenous vein angiography.
I used a mammary catheter for left internal mammary angiography
and native right coronary angiography. A JL-4 catheter was used
for left coronary angiography. I then proceeded with the
intervention as described below.
FINDINGS:
HEMODYNAMICS: LV pressure was 160/13. Aortic pressure 160/83.
RAO LEFT VENTRICULOGRAM: Ventriculography demonstrates left
ventricular systolic function that is well preserved. The
estimated ejection fraction is 50-55%. It is unchanged from prior
to bypass surgery.
CORONARY ANGIOGRAPHY:
LEFT MAIN CORONARY ARTERY: Originates from the left coronary
cusp. It trifurcates into the left anterior descending artery,
ramus intermedius and left circumflex artery. The left main
coronary artery is moderately calcified and severely diseased. At
its origin, is an eccentric 50% plaque. In the distal third of
the left main, at its trifurcation there is a 60-70% stenosis.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left anterior
descending artery is severely diseased throughout its length. It
gives rise to a first diagonal vessel very proximally. This is a
1.5 to 2.0 mm vessel in diameter. It has a tubular 70% stenosis
proximally and a tubular 80% distally. After the first diagonal
vessel, the left anterior descending artery has diffuse 50-70%
stenosis and then is occluded.
RAMUS INTERMEDIUS: The ramus intermedius is a large branching
vessel. It is diffusely diseased. There are sequential 70%
stenoses through its proximal and its mid segments. This was
followed by an 80% stenosis. There is competitive flow distally.
LEFT CIRCUMFLEX CORONARY ARTERY: The left circumflex artery is
occluded at its origin.
RIGHT CORONARY ARTERY: Originates from the right coronary cusp.
It is an anatomically dominant vessel. It is diffusely diseased.
Throughout its mid segment is an eccentric 50% plaquing. The mid
right coronary artery gives rise to an RV marginal branch that
supplies right-to-left collaterals to the apical LAD. That RV
marginal branch has a 90% stenosis. The posterior descending
artery is occluded and fills via left-to-right collaterals. The
posterolateral branch is diffusely diseased and gives off several
small less than 1.0 mm branches. There are right-to-left
collaterals to the occluded distal circumflex.
There is a radial graft to the distal circumflex's obtuse marginal
branch. That vessel is patent.
There is a saphenous vein graft to the ramus intermedius called
OM1 in the surgeon's report. That graft is severely diseased
through its proximal and mid segment with a long tubular 90%
stenosis and TIMI-1 flow.
The free radial graft to the LAD is patent, however, immediately
distal to the anastomosis, there is a new 90% stenosis in the LAD.
This is then followed by diffuse 90% and 95% stenosis in the
distal to transapical segment of the LAD.
INTERVENTION: Based on findings at diagnostic catheterization, we
proceeded with intervention on the vein graft to the ramus
intermedius. Angiomax was administered and a BMW Elite wire was
advanced into the target vessel. A 2.5 x 20 mm balloon was used
to dilate the diseased segment of the proximal to mid saphenous
vein graft. I then positioned a 3.0 x 30 mm Integrity Resolute
stent and deployed it with two inflations up to 12 atmospheres. In
the ostial proximal segment of the graft, I deployed a 2.75 x 14
mm Resolute stent. I then returned with a 3.0 x 30 mm balloon to
the 2.75 mm stent and post deployed it with inflations up to 18
atmospheres. After removal of my balloons and wires, there was
TIMI-3 flow with no perforation, dissection or distal
embolization.
I then turned my attention to the radial graft to the LAD. The
same BMW Elite wire was advanced into the distal LAD. I tried to
advance a 1.5 x 10 mm Sprinter balloon but would not cross through
all the most distal diseased segments of the LAD and I decided to
limit treatment to the new immediate post anastomosis stenosis. I
ballooned this and then deployed a 2.25 x 12 mm Integrity Resolute
at six atmospheres. I removed the stent delivery balloon and then
returned with a 2.25 x 8 mm NC balloon and performed angioplasty
to 12 atmospheres within the stent to ensure there was no
dissection of this very small calcified vessel. After removal of
balloons and wires, we had TIMI-3 flow with no perforation,
dissection or distal embolization.