kimberly_sapp3
New
The docs I work for want to pull every single ting they can, which sadly, sometimes unbundling. How would you all code this? I wanted something to show Im not the only one with this opinion. and we can get the corrected code figured out!
PROCEDURES PERFORMED:
1. Aortic arch angiography.
2. Selective right common carotid angiography with corresponding intracerebral angiography.
3. Selective right vertebral angiography with corresponding intracerebral angiography.
4. Selective left common carotid angiography with corresponding intracerebral angiography.
5. Selective left vertebral angiography with corresponding intracerebral angiography.
INDICATIONS: The patient is a 65-year-old female who underwent a carotid ultrasound which suggests high-grade stenosis of the right internal carotid artery with moderate disease in the left. The patient has a history of stroke and has been referred for diagnostic angiography.
DESCRIPTION OF PROCEDURE: After obtaining appropriate consent, the patient was brought to the cardiac cath lab. The right groin was prepped and draped in sterile fashion. Lidocaine 2% was used to anesthetize the groin.
Using a modified Seldinger technique, a 5-French sheath was introduced into the right common femoral artery. A pigtail catheter was introduced into the ascending thoracic aorta. Aortic arch angiography was performed from this position. At this point, selective angiography was performed. Using a vertebral catheter and a Versacore wire, I navigated the vertebral catheter into the right common carotid artery. From this position angiography was performed with corresponding intracerebral angiography. The catheter was then redirected into the right vertebral artery and from this position right vertebral artery angiography with corresponding intracerebral angiography was performed. The vertebral catheter was then removed back and advanced into the left common carotid artery. From this position left common carotid artery angiography with corresponding intracerebral angiography was performed. The catheter was pulled and redirected into the left subclavian and advanced over the wire into the left vertebral artery. From this position, vertebral artery angiography with corresponding intracerebral angiography was performed. The patient tolerated the procedure well. The equipment was removed.
The patient has baseline neurological deficits which were unchanged after the procedure.
FINDINGS: Aortic valve pressure: 219/97.
ANATOMY:
1. Aortic arch: The aortic arch displays a type I format with all three great vessels arising appropriately. There is minimal disease noted in the aortic arch itself.
2. Left common carotid artery angiography: The left common carotid artery proceeds cephalad and splits off to give what appears to be a very wispy external carotid artery. The internal carotid artery appears to be completely occluded. There is essentially no filling of the internal carotid artery as it enters the cavernous portion, nor in the intracerebral portion, via any collaterals from the external that are readily evident. Of note, the patient does have some degree of motion on the images due to inability to hold her breath which makes the overall imaging quality somewhat limited.
3. Right vertebral artery: The right vertebral artery arises appropriately off the right subclavian artery. There is mild tortuosity in its proximal portion. There is no significant disease in its proximal portion. The vertebral artery itself proceeds cephalad entering the spine and leads directly into the basilar artery. There is no significant obstructive disease noted within the course of the right vertebral artery.
4. Left common carotid artery: The left common carotid artery proceeds cephalad bifurcating appropriately into an internal and external carotid artery. The internal carotid artery has minimal disease with approximately, at most, 20% stenosis in its midportion. The internal carotid artery proceeds cephalad providing full circulation to the intracerebral portion. The MCA and ECA are noted to be patent. There appears to be some degree of filling of the contralateral hemisphere, most notable in the left ACA distribution. It is very difficult to see if the MCA seems to be also filling but there is a hint of MCA filling on the right side notable as well.
5. Left vertebral artery: The left vertebral artery arises off the left subclavian artery. The left vertebral artery itself has minimal diffuse disease. No high-grade stenosis notable. The left vertebral artery proceeds cephalad and combines with the contralateral vertebral artery to form the basilar artery.
CONCLUSIONS:
1. Complete occlusion of the right internal carotid artery notable.
2. Mild disease of the left internal carotid artery with approximately 20-30% stenosis at most.
3. Very poor visualization of the intracerebral vasculature with suggestion of filling of the right hemisphere via the left internal carotid artery distribution. I was not able to delineate any other source for filling of the right hemisphere from either the external carotid artery on either side nor the vertebral arteries.
PLAN: The patient should be continued with aggressive medical therapy. There is no indication for any kind of surgical or intravascular treatment at this point. The patient needs to have better blood pressure control. The patient should be considered for statin therapy as well.
PROCEDURES PERFORMED:
1. Aortic arch angiography.
2. Selective right common carotid angiography with corresponding intracerebral angiography.
3. Selective right vertebral angiography with corresponding intracerebral angiography.
4. Selective left common carotid angiography with corresponding intracerebral angiography.
5. Selective left vertebral angiography with corresponding intracerebral angiography.
INDICATIONS: The patient is a 65-year-old female who underwent a carotid ultrasound which suggests high-grade stenosis of the right internal carotid artery with moderate disease in the left. The patient has a history of stroke and has been referred for diagnostic angiography.
DESCRIPTION OF PROCEDURE: After obtaining appropriate consent, the patient was brought to the cardiac cath lab. The right groin was prepped and draped in sterile fashion. Lidocaine 2% was used to anesthetize the groin.
Using a modified Seldinger technique, a 5-French sheath was introduced into the right common femoral artery. A pigtail catheter was introduced into the ascending thoracic aorta. Aortic arch angiography was performed from this position. At this point, selective angiography was performed. Using a vertebral catheter and a Versacore wire, I navigated the vertebral catheter into the right common carotid artery. From this position angiography was performed with corresponding intracerebral angiography. The catheter was then redirected into the right vertebral artery and from this position right vertebral artery angiography with corresponding intracerebral angiography was performed. The vertebral catheter was then removed back and advanced into the left common carotid artery. From this position left common carotid artery angiography with corresponding intracerebral angiography was performed. The catheter was pulled and redirected into the left subclavian and advanced over the wire into the left vertebral artery. From this position, vertebral artery angiography with corresponding intracerebral angiography was performed. The patient tolerated the procedure well. The equipment was removed.
The patient has baseline neurological deficits which were unchanged after the procedure.
FINDINGS: Aortic valve pressure: 219/97.
ANATOMY:
1. Aortic arch: The aortic arch displays a type I format with all three great vessels arising appropriately. There is minimal disease noted in the aortic arch itself.
2. Left common carotid artery angiography: The left common carotid artery proceeds cephalad and splits off to give what appears to be a very wispy external carotid artery. The internal carotid artery appears to be completely occluded. There is essentially no filling of the internal carotid artery as it enters the cavernous portion, nor in the intracerebral portion, via any collaterals from the external that are readily evident. Of note, the patient does have some degree of motion on the images due to inability to hold her breath which makes the overall imaging quality somewhat limited.
3. Right vertebral artery: The right vertebral artery arises appropriately off the right subclavian artery. There is mild tortuosity in its proximal portion. There is no significant disease in its proximal portion. The vertebral artery itself proceeds cephalad entering the spine and leads directly into the basilar artery. There is no significant obstructive disease noted within the course of the right vertebral artery.
4. Left common carotid artery: The left common carotid artery proceeds cephalad bifurcating appropriately into an internal and external carotid artery. The internal carotid artery has minimal disease with approximately, at most, 20% stenosis in its midportion. The internal carotid artery proceeds cephalad providing full circulation to the intracerebral portion. The MCA and ECA are noted to be patent. There appears to be some degree of filling of the contralateral hemisphere, most notable in the left ACA distribution. It is very difficult to see if the MCA seems to be also filling but there is a hint of MCA filling on the right side notable as well.
5. Left vertebral artery: The left vertebral artery arises off the left subclavian artery. The left vertebral artery itself has minimal diffuse disease. No high-grade stenosis notable. The left vertebral artery proceeds cephalad and combines with the contralateral vertebral artery to form the basilar artery.
CONCLUSIONS:
1. Complete occlusion of the right internal carotid artery notable.
2. Mild disease of the left internal carotid artery with approximately 20-30% stenosis at most.
3. Very poor visualization of the intracerebral vasculature with suggestion of filling of the right hemisphere via the left internal carotid artery distribution. I was not able to delineate any other source for filling of the right hemisphere from either the external carotid artery on either side nor the vertebral arteries.
PLAN: The patient should be continued with aggressive medical therapy. There is no indication for any kind of surgical or intravascular treatment at this point. The patient needs to have better blood pressure control. The patient should be considered for statin therapy as well.
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