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Cardiac catheterization intervention
INDICATIONS: Angina pectoris, coronary artery disease.
Left heart catheterization with selective coronary angiography, bypass graft angiography with complex percutaneous intervention of the left circumflex and first as well as second marginals with placement of sequential Resolute drug-eluting stents
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old diabetic, hypertensive with previous coronary disease and previous bypass grafting in 1990s with LIMA to LAD, vein graft to OM1 and OM2 as well as the vein graft to the RCA. He presented with
progressive symptoms of angina and underwent nuclear stress testing that was intermediate risk for ischemia and despite maximal medical therapy and ongoing symptoms was referred for diagnostic angiography.
PROCEDURE: Informed consent was obtained and the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. The right groin was prepped in the usual sterile fashion and 2% lidocaine infused
subcutaneously until adequate anesthesia was obtained. Right common femoral artery accessed using modified Seldinger technique. A 6-French 11 cm sheath was placed without complication. Diagnostic 6-French JL and JR IMA catheters were used to perform
selective coronary angiography, left heart catheterization and bypass graft angiography. At the conclusion of the procedure, an Angio-Seal device was deployed without complication.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 12 mmHg. There was no transaortic gradient on pullback.
CORONARY ANGIOGRAPHY:
LEFT MAIN CORONARY: Mild disease.
LAD: Totally occluded proximally. The distal vessel was diffusely diseased being fed from a patent bypass graft. The first diagonal was seen feeding in a retrograde fashion from the patent IMA graft that was diffusely diseased.
CIRCUMFLEX: Left circumflex distribution was prominent in caliber that gave off 2 prominent marginal branches. There was a 40% proximal stenosis. There is 60-70% midvessel stenosis leading into an 89% tubular stenotic segment which then bifurcated
with severely diffusely diseased marginals that had 80-90% tubular type-C stenosis each.
RCA: Diffusely diseased and with the distal vessel subtotally occluded. The right PDA was seen filling from a patent bypass graft that had an 80% tubular stenosis. The vein graft to the OM1/OM2 was totally occluded. Vein graft to the right had mild
disease, but otherwise patent. The LIMA to LAD was otherwise patent without significant disease.
SUMMARY: Severe multivessel coronary artery disease with 2/4 bypass grafts patent with diffuse disease in the LAD distribution; however an untended left circumflex distribution with high-grade sequential type-C stenoses as well as a tubular type B
stenosis in the right PDA.
Based on the patient's clinical presentation and angiographic findings, it was elected to proceed with a staged angioplasty of the left circumflex distribution. The patient has mild renal insufficiency and with the contrast offered from the diagnostic
portion as well as the intervention, the right PDA lesion will be approached in a staged fashion.
INTERVENTION: Angiomax was used for effective anticoagulation. An EBU 3.75 guide catheter was used to intubate the left main coronary artery. A Runthrough wire was placed to the second marginal and a Pilot wire was placed to the first marginal. A 2.5
balloon was used to sequentially dilate both segments as well as the bifurcation in the mid and distal left circumflex. Next, a 2.5 x 26 Resolute was then deployed in the lower lying marginal. A 2.5 x 26 Resolute was then deployed in the first
marginal extending across the bifurcation. The wire was then redirected through the stent struts and 1.5 Apex push was used to dilate the stent through the stented segment leading into the stented second marginal system. A 2.5 noncompliant balloon as
well as a 2.5 compliant balloon were inflated to 14 and 10 atmospheres respectively at the bifurcation. Next, a 3.0 x 26 Resolute was then deployed covering the distal left circumflex and there was evidence of a proximal edge dissection, which was
covered with a 3.0 x 15 Resolute. The stent balloon was then used to post-dilate to 18 atmospheres in the overlapping segment with an excellent angiographic result, no residual dissection and TIMI-III flow.
SUMMARY: Successful complex percutaneous intervention of the mid and distal left circumflex first and second marginals with placement of Resolute drug-eluting stents.
We have
93459-26-59
92928-LC
92929-?
92929-?
Dr knows he won't get paid for the 2 92929's but want's them billed but is this correct
INDICATIONS: Angina pectoris, coronary artery disease.
Left heart catheterization with selective coronary angiography, bypass graft angiography with complex percutaneous intervention of the left circumflex and first as well as second marginals with placement of sequential Resolute drug-eluting stents
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old diabetic, hypertensive with previous coronary disease and previous bypass grafting in 1990s with LIMA to LAD, vein graft to OM1 and OM2 as well as the vein graft to the RCA. He presented with
progressive symptoms of angina and underwent nuclear stress testing that was intermediate risk for ischemia and despite maximal medical therapy and ongoing symptoms was referred for diagnostic angiography.
PROCEDURE: Informed consent was obtained and the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. The right groin was prepped in the usual sterile fashion and 2% lidocaine infused
subcutaneously until adequate anesthesia was obtained. Right common femoral artery accessed using modified Seldinger technique. A 6-French 11 cm sheath was placed without complication. Diagnostic 6-French JL and JR IMA catheters were used to perform
selective coronary angiography, left heart catheterization and bypass graft angiography. At the conclusion of the procedure, an Angio-Seal device was deployed without complication.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 12 mmHg. There was no transaortic gradient on pullback.
CORONARY ANGIOGRAPHY:
LEFT MAIN CORONARY: Mild disease.
LAD: Totally occluded proximally. The distal vessel was diffusely diseased being fed from a patent bypass graft. The first diagonal was seen feeding in a retrograde fashion from the patent IMA graft that was diffusely diseased.
CIRCUMFLEX: Left circumflex distribution was prominent in caliber that gave off 2 prominent marginal branches. There was a 40% proximal stenosis. There is 60-70% midvessel stenosis leading into an 89% tubular stenotic segment which then bifurcated
with severely diffusely diseased marginals that had 80-90% tubular type-C stenosis each.
RCA: Diffusely diseased and with the distal vessel subtotally occluded. The right PDA was seen filling from a patent bypass graft that had an 80% tubular stenosis. The vein graft to the OM1/OM2 was totally occluded. Vein graft to the right had mild
disease, but otherwise patent. The LIMA to LAD was otherwise patent without significant disease.
SUMMARY: Severe multivessel coronary artery disease with 2/4 bypass grafts patent with diffuse disease in the LAD distribution; however an untended left circumflex distribution with high-grade sequential type-C stenoses as well as a tubular type B
stenosis in the right PDA.
Based on the patient's clinical presentation and angiographic findings, it was elected to proceed with a staged angioplasty of the left circumflex distribution. The patient has mild renal insufficiency and with the contrast offered from the diagnostic
portion as well as the intervention, the right PDA lesion will be approached in a staged fashion.
INTERVENTION: Angiomax was used for effective anticoagulation. An EBU 3.75 guide catheter was used to intubate the left main coronary artery. A Runthrough wire was placed to the second marginal and a Pilot wire was placed to the first marginal. A 2.5
balloon was used to sequentially dilate both segments as well as the bifurcation in the mid and distal left circumflex. Next, a 2.5 x 26 Resolute was then deployed in the lower lying marginal. A 2.5 x 26 Resolute was then deployed in the first
marginal extending across the bifurcation. The wire was then redirected through the stent struts and 1.5 Apex push was used to dilate the stent through the stented segment leading into the stented second marginal system. A 2.5 noncompliant balloon as
well as a 2.5 compliant balloon were inflated to 14 and 10 atmospheres respectively at the bifurcation. Next, a 3.0 x 26 Resolute was then deployed covering the distal left circumflex and there was evidence of a proximal edge dissection, which was
covered with a 3.0 x 15 Resolute. The stent balloon was then used to post-dilate to 18 atmospheres in the overlapping segment with an excellent angiographic result, no residual dissection and TIMI-III flow.
SUMMARY: Successful complex percutaneous intervention of the mid and distal left circumflex first and second marginals with placement of Resolute drug-eluting stents.
We have
93459-26-59
92928-LC
92929-?
92929-?
Dr knows he won't get paid for the 2 92929's but want's them billed but is this correct