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INDICATIONS: Angina pectoris.
Left heart catheterization, selective coronary angiography, bypass graft angiography with complex percutaneous intervention of the proximal LAD with balloon angioplasty and proximal left circumflex with placement of a drug-eluting stent
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old with history of hypertension, CAD, previous mitral valve repair and bypass surgery in 2010. There he had received a LIMA to LAD and a reported vein graft to the marginal and vein graft to the
RCA. He has had issues with paroxysmal atrial fibrillation and sinus node dysfunction and subsequently received a pacemaker; however, because of residual fatigue and shortness of breath, he presents 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 of which a 6 French 11 cm sheath was placed. Significant tortuosity and calcification were encountered. Iliac angiography
demonstrated calcification at the arteriotomy site. At the conclusion of the procedure, manual compression was used for hemostasis.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 10 mmHg. There was no transaortic gradient on pullback.
Subclavian angiography demonstrated critical proximal subclavian stenosis of 70-80% with a 60-70 mmHg across the subclavian on pullback.
CORONARY ANGIOGRAPHY:
LEFT MAIN: 80% distal left main stenosis.
LAD: 90% ostial stenosis. There was moderate diffuse disease. The distal vessel was seen filled from a retrograde contribution of a patent diagonal graft. There was retrograde filling of the IMA with antegrade left injection. The diagonal appeared to
have an 80% proximal stenosis.
LEFT CIRCUMFLEX: Had an 80-90% ostial and proximal stenosis. There are two prominent marginals and continuation into the AV groove and had moderate diffuse disease.
RCA: Totally occluded proximally. There was a patent graft seen in the distal vessel with diffuse disease. The vein graft to the RCA was small in caliber, however, only mild disease. The vein graft to the diagonal was patent with mild disease. This
is different from what was reported. In the operative report, there is no vein graft to the marginal. The LIMA to the LAD was atretic without filling of antegrade contrast to the heart in light of competitive retrograde flow likely due to subclavian
stenosis.
SUMMARY: Critical multivessel coronary artery disease with distal left main, LAD, and circumflex stenosis. Critical subclavian stenosis compromising antegrade flow from an IMA graft. No evidence of circumflex bypass, thus indicating compromise of
flow to the left circumflex distribution.
Based on the patient's clinical presentation and apparent lack revascularization to the lateral wall, it was elected to proceed with angioplasty.
INTERVENTION: Angiomax was used for effective anticoagulation and an EBU 3.75 guide catheter was used to intubate the left main coronary artery. A Runthrough wire was placed to the distal circumflex and an ATW wire was placed to the distal LAD. A 2.5
balloon was used to predilate the lesion in the LAD with effective balloon angioplasty of the LAD with 0% residual stenosis. Next, the balloon was then redirected across the Runthrough wire into the proximal left circumflex and was dilated to 6
atmospheres. A 3.0 x 15 Resolute drug-eluting stent was then deployed and postdilated with a 3.5 x 12 noncompliant balloon to 18 atmospheres with an excellent angiographic result and TIMI-III flow.
SUMMARY: Successful percutaneous intervention of the proximal left circumflex with placement of a rather drug-eluting stent, balloon angioplasty of the LAD.
I have
93459-26-59
92928-LC
92920-LD
36225-26
Am I correct and any other modifiers on the 36225
Left heart catheterization, selective coronary angiography, bypass graft angiography with complex percutaneous intervention of the proximal LAD with balloon angioplasty and proximal left circumflex with placement of a drug-eluting stent
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old with history of hypertension, CAD, previous mitral valve repair and bypass surgery in 2010. There he had received a LIMA to LAD and a reported vein graft to the marginal and vein graft to the
RCA. He has had issues with paroxysmal atrial fibrillation and sinus node dysfunction and subsequently received a pacemaker; however, because of residual fatigue and shortness of breath, he presents 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 of which a 6 French 11 cm sheath was placed. Significant tortuosity and calcification were encountered. Iliac angiography
demonstrated calcification at the arteriotomy site. At the conclusion of the procedure, manual compression was used for hemostasis.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 10 mmHg. There was no transaortic gradient on pullback.
Subclavian angiography demonstrated critical proximal subclavian stenosis of 70-80% with a 60-70 mmHg across the subclavian on pullback.
CORONARY ANGIOGRAPHY:
LEFT MAIN: 80% distal left main stenosis.
LAD: 90% ostial stenosis. There was moderate diffuse disease. The distal vessel was seen filled from a retrograde contribution of a patent diagonal graft. There was retrograde filling of the IMA with antegrade left injection. The diagonal appeared to
have an 80% proximal stenosis.
LEFT CIRCUMFLEX: Had an 80-90% ostial and proximal stenosis. There are two prominent marginals and continuation into the AV groove and had moderate diffuse disease.
RCA: Totally occluded proximally. There was a patent graft seen in the distal vessel with diffuse disease. The vein graft to the RCA was small in caliber, however, only mild disease. The vein graft to the diagonal was patent with mild disease. This
is different from what was reported. In the operative report, there is no vein graft to the marginal. The LIMA to the LAD was atretic without filling of antegrade contrast to the heart in light of competitive retrograde flow likely due to subclavian
stenosis.
SUMMARY: Critical multivessel coronary artery disease with distal left main, LAD, and circumflex stenosis. Critical subclavian stenosis compromising antegrade flow from an IMA graft. No evidence of circumflex bypass, thus indicating compromise of
flow to the left circumflex distribution.
Based on the patient's clinical presentation and apparent lack revascularization to the lateral wall, it was elected to proceed with angioplasty.
INTERVENTION: Angiomax was used for effective anticoagulation and an EBU 3.75 guide catheter was used to intubate the left main coronary artery. A Runthrough wire was placed to the distal circumflex and an ATW wire was placed to the distal LAD. A 2.5
balloon was used to predilate the lesion in the LAD with effective balloon angioplasty of the LAD with 0% residual stenosis. Next, the balloon was then redirected across the Runthrough wire into the proximal left circumflex and was dilated to 6
atmospheres. A 3.0 x 15 Resolute drug-eluting stent was then deployed and postdilated with a 3.5 x 12 noncompliant balloon to 18 atmospheres with an excellent angiographic result and TIMI-III flow.
SUMMARY: Successful percutaneous intervention of the proximal left circumflex with placement of a rather drug-eluting stent, balloon angioplasty of the LAD.
I have
93459-26-59
92928-LC
92920-LD
36225-26
Am I correct and any other modifiers on the 36225
