OK, would someone please be willing to read this and let me know about codes?
I have:
93454.26
36221
92928.RC
92978.26.RC
75710.26
I'm stuck on the rest. Could the 35475/75962.26 be used for PTA of radial artery? Any catheter placement code I may be missing? Uggh, this one was a doozy for me.
Jessica CPC, CCC
DESCRIPTION OF PROCEDURE: After informed consent with the patient felt to be a good candidate for conscious sedation, he had a normal Allen's test at his wrist with a normal Barbeau oxygen test at the wrist compression of his radial artery showing maintained oxygen saturation with a good triphasic signal, which was not damped. This suggested an intact bidirectional radial artery flow and likely an intact palmar arterial arch to consider a radial approach.
He had local anesthesia to the right radial artery area and a 6-French sheath was inserted under micropuncture Seldinger technique relatively easily given a fairly easily bounding palpable radial arterial pulse. In retrospect, it was inadvertently recognized that the patient had an accessory right radial functioning as an ulnar right beside the access site that was accessed rather than the true radial as seen later in the procedure. A 6-French sheath tapered sheath was inserted after micro-puncture set technique. He was heparinized with 5000 units of Heparin in the right radial with cocktail consisting of Verapamil, heparinized saline, and Nitroglycerin inserted via the sheath Using a 190 mm length J-wire, a Jacky catheter was advanced up with Right coronary artery evaluation performed first. The same catheter was used to advance to the left coronary sinus and left coronary angiography was performed. This did not reach as well as I would like to, but eventually with some additional maneuvers, I was able to get it to engage the left coronary system. Following this, the catheter was removed over the J-wire and I opted to give the patient additional Heparin as his ACT was somewhat low and proceed with consideration of right coronary artery IVUS evaluation. I attempted to advance an Amplatz AL-1 guide in anticipation of performing intravascular ultrasound, but could not re-advance the J-wire beyond the mid portion of his forearm. It was encountering a fair bit of spasm. Sublingual Nitroglycerin was given and despite this, I still could not advance the J-wire. I opted to perform a radial angiogram via the sheath in a retrograde fashion. This revealed a 95% lesion with serial areas of disease and/or spasm in the distal portion of the upper arm. Additional views done in a retrograde fashion further up show that this artery was likely an accessory radial but had spasm all the way up to near its origin from the brachial and/or main radial artery in the mid upper arm. After a period of observation, the patient continued to have reduced saturation at the wrist and was seen to have a 35 mm gradient with a systolic blood pressure of 75 at the radial sheath versus a central pressure by left brachial cuff of 100-110 mm Hg. After a period of observation and additional heparinization, I could not relieve the spasm in this area which persisted and by this time, he was having severe pain in his lower forearm. I opted to pass an All Star wire across the lesion from the wrist access, which went relatively smoothly, placing this in the subclavian trunk near its origin with the aorta. I opted to do a low pressure balloon inflation with a 2.5 x 150 mm Sterling over-The-Wire balloon. This was inflated serially over the length of the area of spasm to medium followed by high pressures. Despite this, there was improved distal flow, but the patient continued to have pain. I opted to perform additional high-pressure inflation after a period of observation and seen that the spasm was persistent with the wire remaining across the lesion. With the additional inflations, the patient had a significant vagal reaction with the blood pressure drop into the 50 systolic range due to severe arm pain he was having. With this drop in blood pressure, there was reduced flow as seen via the radial sheath at the wrist and given the low blood pressure, I opted to place the patient urgently on Dopamine titrated to 10 mcg/kg per minute. This led to a transient atrial tachycardia which subsequently resolved with reducing the dose. Patient had a fluid bolus given wide open and after a period of 7-10 minutes, blood pressure stabilized, was able to get off of Dopamine. In the meantime, I accessed the right common femoral artery with a Seldinger technique placing a 6-French sheath in this. I used a JR4 6-French catheter advanced over a J-wire to try to find the entry to the subclavian, but it was not successful in doing this without an arch aortogram which was performed via this right 6-French JR4 catheter with a selective arch angiogram. This helped me to locate the right subclavian origin and using an exchange length Glidewire, I was able to advance into the upper portion of the brachial and distal portion of the right subclavian artery with the JR4 catheter. Through this JR4 catheter, I was able to perform an angiogram showing that there was a fair bit of spasm around the residual All Star wire across the lesion and I opted to remove this wire from the radial at the wrist . As there was still persistent decreased flow across this area and reduced flow at the distal radial, I opted to remove the radial sheath performing more aggressive heparinization of the patient and despite additional doses of Heparin, the patient still had a somewhat lower ACT suggesting that he may have been consuming Heparin. Once the patient was hemodynamically stable clinically with better blood pressures and off Dopamine, I continued to run fluids as 50 mL per hour of saline. I opted to remove the right radial sheath using Hemoband hemostasis, and with a very short time after removing all of this hardware, there was improvement in the right radial oxygen plethysmography with a normal signal at the right thumb and a normal waveform. Oxygen saturation was maintained at 98% the rest of The procedure.
There was good hemostasis achieved via a radial TR band. By this time, the patient's transient nausea had improved with the use of Zofran and with improvement of blood pressure. His hemodynamics were completely stable. I reviewed the results to that point with him and his wife and after a period of observation of another 15-20 minutes to ensure that he was stable, I asked him whether we wanted to continue to pursue the right coronary artery evaluation with a view toward intervention and now let all the hardware was out on the table that a right groin access was already established. He wanted to be watched for a little while and after confirming additional stability, he and his wife made the decision to proceed with completion of the procedure.
Using an Amplatz AL-1 guide engaged in the right coronary artery from the right CFA approach, I advanced an All Star wire across the proximal lesion and proceeded with intravascular ultrasound. This revealed a minimal luminal area of 2.5 mm2 in an 18.9 mm2 artery, representing 1.5 x 2 mm channel in a 4.7 x 5.1 mm artery consistent with an 87% lesion. There were very mild fibrotic elements in the outer portions of the lesion with more distally showing a slight amount of calcium. I opted to proceed with direct stenting with a 4.5 x 18 mm Ultra stent, deployed to medium pressures and postdilated to high pressures. There was some area of distal spasm for which I could not tell whether this was a dissection plane or spasm and performed a low pressure balloon inflation with this balloon to 2 to 4 atmospheres in this area serially. Eventually, it was realized that there was a dissection plane in this area and I opted to place a 4.0 x 13 mm Veriflex stent in tandem with the other more proximal stent deploying to high pressures and postdilated the junction of the 2 stents and using the same stent balloon to aggressively dilate the more proximal stent throughout its margins to high pressures. After confirming an excellent procedure result with the patient given intracoronary Nitroglycerin, 100 mcg aliquot x1 to ensure that there was no residual spasm, all hardware was removed and confirming an excellent result, the patient was apprised of the findings.
He had a right common femoral artery angiogram showing appropriate sheath access site despite previous Angio-Seal, which appears to be now healed despite a previous Perclose and prior Angioseal both placed around 3-4 weeks ago. An Angio-Seal closure of the 6-French variety was done with good hemostasis at the groin.
The right radial maintained normal saturation throughout the rest of the procedure despite Hemoband being in place.
He was transferred to the postprocedure recovery room where he was observed for additional 5 hours with intact right radial circulation with a saturation of 95% to 98% throughout the rest of his hospital stay, which was confirmed to be maintained even after removing of the Hemoband. He did not have any further sequelae, though he did have some mild oozing at the groin due to aggressive use of Heparin during the procedure without any further problems.
He was to be discharged home on Aspirin and Brilinta in addition to his Lisinopril, Metoprolol, and statin medication in addition to his stomach medications.
It is anticipated he will be seen in followup in a couple weeks' time or sooner if he has problems. Of note, following a right coronary intervention, his blood pressure was more stable than it has been in the last couple of weeks, having had a systolic blood pressure of 120-130 in the holding recovery whereas it was running barely 100-105mm Hg, possibly 110 before the procedure.
He will also be maintained on long-acting nitrate, which were already in place, which should help with any residual and/or recurrent radial artery spasm. Of note, his right wrist had normal strength of his hands, normal color, no evidence of embolization, no mottling of any of his finger, and normal saturations when reassessed prior to discharge.
Angiographic findings:
Findings on ipsilateral selective right radial artery evaluation via the 6-French sheath, it appears to be accessed via an accessory right radial rather than true radial. There was significant spasm just above the elbow in the accessory right radial which extends all the way to its origin from the main radial and/or brachial artery in the mid upper arm level.
Findings on the ipsilateral selective right subclavian and/or upper brachial artery angiogram via the 6-French diagnostic right coronary catheter performed from the right CFA approach reveals patent flow with normal runoff in the main radial artery to the level of the wrist. There was transient significant spasm in the accessory radial and/or equivalent anomalous origin ulnar artery, which was the artery that was accessed. The spasm persisted around wire hardware, improved following balloon inflation, and further improved following removal of the right radial sheath. There was transient severely decreased flow in this artery, especially in its mid to distal portion toward the wrist. This spasm slowly improved following removal of hardware, such that the palmar arch was seen to be intact though anomalous in its origin as the right radial artery and anomalous accessory radial functioning as the ulnar were superimposed almost beside each other in the wrist on thumb surface of the wrist.
Arch angiogram performed via the JR4 catheter reveals somewhat tortuous origin to the brachiocephalic trunk arch and tortuous origin of the subclavian off the main right subclavian common carotid trunk. The right common carotid appeared to be free of disease with unplanned inadvertent visualization.
Findings on right common femoral artery angiogram; appropriate sheath access site with no evidence of any intraluminal filling defects from previous Angio-Seal or previous Perclose performance.
Left main appears to be large and appears to be free of significant disease.
Left anterior descending has patent stents in its proximal and mid portion with mild luminal irregularities in its distal portion.
The first diagonal appears to have had mild plaque shift into its origin with medium caliber, but appeared to have TIMI-3 flow and thus opted not to perform intervention on this moderate lesion, which did not appear to be obstructive. Tiny additional diagonals further down appeared to have mild luminal irregularities. The left anterior descending was large and appeared to reach the apex.
The circumflex is a large caliber artery, had mild 20% to 30% disease in its proximal and distal portion before giving rise to a sizeable obtuse marginal and some smaller branches which were free of significant disease.
The right coronary artery was an anterior-inferior origin followed by a shepherd's crook type of picture. There appeared to be a 5 mm caliber proximally followed by 4 mm caliber distally. There was a 50% to 60% visibly appearing lesion (later seen to be very high grade by IVUS as above)was seen in 2 views suggesting that it potentially was tight with mild calcifications seen in its proximal portion and mild luminal irregularities in its mid portion. It gave rise to a large posterolateral branch and early arising posterior descending, which was relatively small.
Findings of the RCA by intravascular ultrasound are described above.
Left heart catheterization was not performed.
Completion angiography performed via the JR4 catheter of the subclavian/upper brachial showed marked improvement in the caliber and runoff in the accessory radial and/or functional ulnar artery as well as the main radial down to the level of the wrist on digital subtraction angiography.
I have:
93454.26
36221
92928.RC
92978.26.RC
75710.26
I'm stuck on the rest. Could the 35475/75962.26 be used for PTA of radial artery? Any catheter placement code I may be missing? Uggh, this one was a doozy for me.
Jessica CPC, CCC
DESCRIPTION OF PROCEDURE: After informed consent with the patient felt to be a good candidate for conscious sedation, he had a normal Allen's test at his wrist with a normal Barbeau oxygen test at the wrist compression of his radial artery showing maintained oxygen saturation with a good triphasic signal, which was not damped. This suggested an intact bidirectional radial artery flow and likely an intact palmar arterial arch to consider a radial approach.
He had local anesthesia to the right radial artery area and a 6-French sheath was inserted under micropuncture Seldinger technique relatively easily given a fairly easily bounding palpable radial arterial pulse. In retrospect, it was inadvertently recognized that the patient had an accessory right radial functioning as an ulnar right beside the access site that was accessed rather than the true radial as seen later in the procedure. A 6-French sheath tapered sheath was inserted after micro-puncture set technique. He was heparinized with 5000 units of Heparin in the right radial with cocktail consisting of Verapamil, heparinized saline, and Nitroglycerin inserted via the sheath Using a 190 mm length J-wire, a Jacky catheter was advanced up with Right coronary artery evaluation performed first. The same catheter was used to advance to the left coronary sinus and left coronary angiography was performed. This did not reach as well as I would like to, but eventually with some additional maneuvers, I was able to get it to engage the left coronary system. Following this, the catheter was removed over the J-wire and I opted to give the patient additional Heparin as his ACT was somewhat low and proceed with consideration of right coronary artery IVUS evaluation. I attempted to advance an Amplatz AL-1 guide in anticipation of performing intravascular ultrasound, but could not re-advance the J-wire beyond the mid portion of his forearm. It was encountering a fair bit of spasm. Sublingual Nitroglycerin was given and despite this, I still could not advance the J-wire. I opted to perform a radial angiogram via the sheath in a retrograde fashion. This revealed a 95% lesion with serial areas of disease and/or spasm in the distal portion of the upper arm. Additional views done in a retrograde fashion further up show that this artery was likely an accessory radial but had spasm all the way up to near its origin from the brachial and/or main radial artery in the mid upper arm. After a period of observation, the patient continued to have reduced saturation at the wrist and was seen to have a 35 mm gradient with a systolic blood pressure of 75 at the radial sheath versus a central pressure by left brachial cuff of 100-110 mm Hg. After a period of observation and additional heparinization, I could not relieve the spasm in this area which persisted and by this time, he was having severe pain in his lower forearm. I opted to pass an All Star wire across the lesion from the wrist access, which went relatively smoothly, placing this in the subclavian trunk near its origin with the aorta. I opted to do a low pressure balloon inflation with a 2.5 x 150 mm Sterling over-The-Wire balloon. This was inflated serially over the length of the area of spasm to medium followed by high pressures. Despite this, there was improved distal flow, but the patient continued to have pain. I opted to perform additional high-pressure inflation after a period of observation and seen that the spasm was persistent with the wire remaining across the lesion. With the additional inflations, the patient had a significant vagal reaction with the blood pressure drop into the 50 systolic range due to severe arm pain he was having. With this drop in blood pressure, there was reduced flow as seen via the radial sheath at the wrist and given the low blood pressure, I opted to place the patient urgently on Dopamine titrated to 10 mcg/kg per minute. This led to a transient atrial tachycardia which subsequently resolved with reducing the dose. Patient had a fluid bolus given wide open and after a period of 7-10 minutes, blood pressure stabilized, was able to get off of Dopamine. In the meantime, I accessed the right common femoral artery with a Seldinger technique placing a 6-French sheath in this. I used a JR4 6-French catheter advanced over a J-wire to try to find the entry to the subclavian, but it was not successful in doing this without an arch aortogram which was performed via this right 6-French JR4 catheter with a selective arch angiogram. This helped me to locate the right subclavian origin and using an exchange length Glidewire, I was able to advance into the upper portion of the brachial and distal portion of the right subclavian artery with the JR4 catheter. Through this JR4 catheter, I was able to perform an angiogram showing that there was a fair bit of spasm around the residual All Star wire across the lesion and I opted to remove this wire from the radial at the wrist . As there was still persistent decreased flow across this area and reduced flow at the distal radial, I opted to remove the radial sheath performing more aggressive heparinization of the patient and despite additional doses of Heparin, the patient still had a somewhat lower ACT suggesting that he may have been consuming Heparin. Once the patient was hemodynamically stable clinically with better blood pressures and off Dopamine, I continued to run fluids as 50 mL per hour of saline. I opted to remove the right radial sheath using Hemoband hemostasis, and with a very short time after removing all of this hardware, there was improvement in the right radial oxygen plethysmography with a normal signal at the right thumb and a normal waveform. Oxygen saturation was maintained at 98% the rest of The procedure.
There was good hemostasis achieved via a radial TR band. By this time, the patient's transient nausea had improved with the use of Zofran and with improvement of blood pressure. His hemodynamics were completely stable. I reviewed the results to that point with him and his wife and after a period of observation of another 15-20 minutes to ensure that he was stable, I asked him whether we wanted to continue to pursue the right coronary artery evaluation with a view toward intervention and now let all the hardware was out on the table that a right groin access was already established. He wanted to be watched for a little while and after confirming additional stability, he and his wife made the decision to proceed with completion of the procedure.
Using an Amplatz AL-1 guide engaged in the right coronary artery from the right CFA approach, I advanced an All Star wire across the proximal lesion and proceeded with intravascular ultrasound. This revealed a minimal luminal area of 2.5 mm2 in an 18.9 mm2 artery, representing 1.5 x 2 mm channel in a 4.7 x 5.1 mm artery consistent with an 87% lesion. There were very mild fibrotic elements in the outer portions of the lesion with more distally showing a slight amount of calcium. I opted to proceed with direct stenting with a 4.5 x 18 mm Ultra stent, deployed to medium pressures and postdilated to high pressures. There was some area of distal spasm for which I could not tell whether this was a dissection plane or spasm and performed a low pressure balloon inflation with this balloon to 2 to 4 atmospheres in this area serially. Eventually, it was realized that there was a dissection plane in this area and I opted to place a 4.0 x 13 mm Veriflex stent in tandem with the other more proximal stent deploying to high pressures and postdilated the junction of the 2 stents and using the same stent balloon to aggressively dilate the more proximal stent throughout its margins to high pressures. After confirming an excellent procedure result with the patient given intracoronary Nitroglycerin, 100 mcg aliquot x1 to ensure that there was no residual spasm, all hardware was removed and confirming an excellent result, the patient was apprised of the findings.
He had a right common femoral artery angiogram showing appropriate sheath access site despite previous Angio-Seal, which appears to be now healed despite a previous Perclose and prior Angioseal both placed around 3-4 weeks ago. An Angio-Seal closure of the 6-French variety was done with good hemostasis at the groin.
The right radial maintained normal saturation throughout the rest of the procedure despite Hemoband being in place.
He was transferred to the postprocedure recovery room where he was observed for additional 5 hours with intact right radial circulation with a saturation of 95% to 98% throughout the rest of his hospital stay, which was confirmed to be maintained even after removing of the Hemoband. He did not have any further sequelae, though he did have some mild oozing at the groin due to aggressive use of Heparin during the procedure without any further problems.
He was to be discharged home on Aspirin and Brilinta in addition to his Lisinopril, Metoprolol, and statin medication in addition to his stomach medications.
It is anticipated he will be seen in followup in a couple weeks' time or sooner if he has problems. Of note, following a right coronary intervention, his blood pressure was more stable than it has been in the last couple of weeks, having had a systolic blood pressure of 120-130 in the holding recovery whereas it was running barely 100-105mm Hg, possibly 110 before the procedure.
He will also be maintained on long-acting nitrate, which were already in place, which should help with any residual and/or recurrent radial artery spasm. Of note, his right wrist had normal strength of his hands, normal color, no evidence of embolization, no mottling of any of his finger, and normal saturations when reassessed prior to discharge.
Angiographic findings:
Findings on ipsilateral selective right radial artery evaluation via the 6-French sheath, it appears to be accessed via an accessory right radial rather than true radial. There was significant spasm just above the elbow in the accessory right radial which extends all the way to its origin from the main radial and/or brachial artery in the mid upper arm level.
Findings on the ipsilateral selective right subclavian and/or upper brachial artery angiogram via the 6-French diagnostic right coronary catheter performed from the right CFA approach reveals patent flow with normal runoff in the main radial artery to the level of the wrist. There was transient significant spasm in the accessory radial and/or equivalent anomalous origin ulnar artery, which was the artery that was accessed. The spasm persisted around wire hardware, improved following balloon inflation, and further improved following removal of the right radial sheath. There was transient severely decreased flow in this artery, especially in its mid to distal portion toward the wrist. This spasm slowly improved following removal of hardware, such that the palmar arch was seen to be intact though anomalous in its origin as the right radial artery and anomalous accessory radial functioning as the ulnar were superimposed almost beside each other in the wrist on thumb surface of the wrist.
Arch angiogram performed via the JR4 catheter reveals somewhat tortuous origin to the brachiocephalic trunk arch and tortuous origin of the subclavian off the main right subclavian common carotid trunk. The right common carotid appeared to be free of disease with unplanned inadvertent visualization.
Findings on right common femoral artery angiogram; appropriate sheath access site with no evidence of any intraluminal filling defects from previous Angio-Seal or previous Perclose performance.
Left main appears to be large and appears to be free of significant disease.
Left anterior descending has patent stents in its proximal and mid portion with mild luminal irregularities in its distal portion.
The first diagonal appears to have had mild plaque shift into its origin with medium caliber, but appeared to have TIMI-3 flow and thus opted not to perform intervention on this moderate lesion, which did not appear to be obstructive. Tiny additional diagonals further down appeared to have mild luminal irregularities. The left anterior descending was large and appeared to reach the apex.
The circumflex is a large caliber artery, had mild 20% to 30% disease in its proximal and distal portion before giving rise to a sizeable obtuse marginal and some smaller branches which were free of significant disease.
The right coronary artery was an anterior-inferior origin followed by a shepherd's crook type of picture. There appeared to be a 5 mm caliber proximally followed by 4 mm caliber distally. There was a 50% to 60% visibly appearing lesion (later seen to be very high grade by IVUS as above)was seen in 2 views suggesting that it potentially was tight with mild calcifications seen in its proximal portion and mild luminal irregularities in its mid portion. It gave rise to a large posterolateral branch and early arising posterior descending, which was relatively small.
Findings of the RCA by intravascular ultrasound are described above.
Left heart catheterization was not performed.
Completion angiography performed via the JR4 catheter of the subclavian/upper brachial showed marked improvement in the caliber and runoff in the accessory radial and/or functional ulnar artery as well as the main radial down to the level of the wrist on digital subtraction angiography.