tosborne
Contributor
I am having trouble with a note, could someone please review and give your opinion on the correct codes.
Indication: Staged intervention after recent non-ST-elevation myocardial infarction with stenting of the right coronary arter in the setting of ongoing chest pain and ventricular tachycardia, who now presents for a staged intervention to the proximal LAD involving the origin of a diaganal.
Procedures: Percutaneous coronary intervention with stenting of proximal to mid left anterior descending with a 3.0 x 30mm Endeavor drug eluting stent.
2. Status post plain old balloon angioplasty of the first diagonal branch.
Procedure details: The patient was subsequent brought the the cardiac cath lab, prepped and draped in the usual sterile fashion. A 7- French Pinnacle sheath was placed in right brachial artery, in the usual manner, using 1% lidocaine as the anesthetic, in a micropunture technique. Next, Angiomax was administered and a 7-French EBU 3.0 guide catheter was advaned into the ascending aorta, and subsequently used to selectively engage the left main trunk. The EBU 3.0 gide catheter did not sit well. Therefore, it was removed and a 7-French AL1 guide catheter was advanced into the ascending aorta over a guidewire, and used to selectivley engage the left main trunk. The AL1 catheter provided excellent support. Next Prowater wire was advanced into the distal LAD and a Whisper wire was advanced into the first diagonal. Balloon angioplasty of the first diagonal was performed using a 2.0 x 12mm Trek balloon. The Trek balloon was then removed and the LAD was stented with a 3.0 x 30mm Endeavor DES. This demonstrated an excellent result in the LAD, however there was still severe residula (80%) desease atthe origin of the diagonal. The diagonal was subsequently re-wired with Pilot 50 coronary wire and the Whisper was removed. Next, simultaneous kissing balloon inflations were performed with a 2.0 x 15mm NC Trek balloon and a 3.0 x 15mm NC Sprinter balloon at 7 atmospheres. THe balloons were then removed and a repeat coronary angiogram again still demostrated at least a 50% residual lesion in the origin of the diagonal. Therefore, I decided to again to again balloon the origin of the diagonal, this time using a 2.5 x 15mm NC Sprinter balloon. This demonstrated a very good result with less than 20% residual stenosis. Next, a final inflation was perfomred using a kissing balloon technique with the 3.0 x 15mm NC Sprinter balloon in the LAD and the 2.5 x 15mm in the diagonal. The diagonal balloon was inflated at 5 atomspheres and the LAD at 8 atomspheres. All equipment was then removed and a repeat coronary angiogram demonstrated TIMI-3 flow in the LAD, with no residual stenosis. The origin of the diagonal has less than 20% residual stenosis. THere was no evidence of dissection or perforation. The patient tolerated the procedure well and there were no complications observed.
HEMODYNAMICS: Aortice pressure is 125/75 mmHg
CONTRAST DOSE: 150 mL of Visipaque contrast
RADIATION DOSE: 5279 mGY
IMPRESSION: Severe disease in the proximal left anterior descending involving the orignin of a medium size first diagonal branch.
PLAN: 1. The patinet is now status post successful percutaneous coronary intervention of the proximal to mid LAD with a 3.0 x 30mm Endeavor drug eluting stent and plain old balloon angioplasty of the first diagonal with an excellent result.
2. The patient will need agressive atherosclerotic risk factor modification. Will need at least one year of dual antiplatelet therapy.
any input will be greatly appreciated. This has be totally stumped.
Indication: Staged intervention after recent non-ST-elevation myocardial infarction with stenting of the right coronary arter in the setting of ongoing chest pain and ventricular tachycardia, who now presents for a staged intervention to the proximal LAD involving the origin of a diaganal.
Procedures: Percutaneous coronary intervention with stenting of proximal to mid left anterior descending with a 3.0 x 30mm Endeavor drug eluting stent.
2. Status post plain old balloon angioplasty of the first diagonal branch.
Procedure details: The patient was subsequent brought the the cardiac cath lab, prepped and draped in the usual sterile fashion. A 7- French Pinnacle sheath was placed in right brachial artery, in the usual manner, using 1% lidocaine as the anesthetic, in a micropunture technique. Next, Angiomax was administered and a 7-French EBU 3.0 guide catheter was advaned into the ascending aorta, and subsequently used to selectively engage the left main trunk. The EBU 3.0 gide catheter did not sit well. Therefore, it was removed and a 7-French AL1 guide catheter was advanced into the ascending aorta over a guidewire, and used to selectivley engage the left main trunk. The AL1 catheter provided excellent support. Next Prowater wire was advanced into the distal LAD and a Whisper wire was advanced into the first diagonal. Balloon angioplasty of the first diagonal was performed using a 2.0 x 12mm Trek balloon. The Trek balloon was then removed and the LAD was stented with a 3.0 x 30mm Endeavor DES. This demonstrated an excellent result in the LAD, however there was still severe residula (80%) desease atthe origin of the diagonal. The diagonal was subsequently re-wired with Pilot 50 coronary wire and the Whisper was removed. Next, simultaneous kissing balloon inflations were performed with a 2.0 x 15mm NC Trek balloon and a 3.0 x 15mm NC Sprinter balloon at 7 atmospheres. THe balloons were then removed and a repeat coronary angiogram again still demostrated at least a 50% residual lesion in the origin of the diagonal. Therefore, I decided to again to again balloon the origin of the diagonal, this time using a 2.5 x 15mm NC Sprinter balloon. This demonstrated a very good result with less than 20% residual stenosis. Next, a final inflation was perfomred using a kissing balloon technique with the 3.0 x 15mm NC Sprinter balloon in the LAD and the 2.5 x 15mm in the diagonal. The diagonal balloon was inflated at 5 atomspheres and the LAD at 8 atomspheres. All equipment was then removed and a repeat coronary angiogram demonstrated TIMI-3 flow in the LAD, with no residual stenosis. The origin of the diagonal has less than 20% residual stenosis. THere was no evidence of dissection or perforation. The patient tolerated the procedure well and there were no complications observed.
HEMODYNAMICS: Aortice pressure is 125/75 mmHg
CONTRAST DOSE: 150 mL of Visipaque contrast
RADIATION DOSE: 5279 mGY
IMPRESSION: Severe disease in the proximal left anterior descending involving the orignin of a medium size first diagonal branch.
PLAN: 1. The patinet is now status post successful percutaneous coronary intervention of the proximal to mid LAD with a 3.0 x 30mm Endeavor drug eluting stent and plain old balloon angioplasty of the first diagonal with an excellent result.
2. The patient will need agressive atherosclerotic risk factor modification. Will need at least one year of dual antiplatelet therapy.
any input will be greatly appreciated. This has be totally stumped.