stpat
Networker
I am coming up with 37205, 36223 36215-59 75960-26 and 75710-26-59 for this op report. Is anyone else getting something different? I question whether I should be using 36225 for the cath placement and angiography in the left subclavian.
TECHNIQUE: Informed consent was obtained. The patient was taken to the
catheterization lab. A 6-French sheath was started in the right common
femoral artery using modified Seldinger technique. A pigtail catheter
was advanced to the ascending arch, and ascending aortic arch
angiography was obtained. Catheter pulled back and exchanged for an H1
catheter and engaged the left subclavian. Left subclavian angiography
was obtained. Catheter exchanged for a Judkins right 4.0 catheter,
engaged the left common carotid artery. Angiography was obtained as well
as cerebral angiography. Catheter was pulled back, noted significant,
greater than 50 mm gradient with crossing that ostial carotid stenosis.
Next, percutaneous intervention as below. After that, equipment removed,
sheath sewn in place, to be pulled when the ACT is less than 160 seconds
per protocol.
HEMODYNAMICS: Aortic pressure 185/54. Closing pressure 149/60.
ANGIOGRAPHY: Ascending arch with significant heavy calcium deposition,
a type 3 aortic arch. Brachiocephalic artery without significant
stenosis. Right common carotid not imaged. Left common carotid with
ostial 80% severe stenosis. Left internal carotid with only 50%, mild to
moderate stenosis. Left anterior cerebral arteries suboptimally
visualized. Left middle cerebral artery without obvious cutoff.
Left subclavian with long heavy calcium, stenosis 90%.
PERCUTANEOUS INTERVENTION: Adjunctive heparin given to reduce major
adverse cardiac events after the 5-French sheath was swapped out for a 6-
French Shuttle sheath. Shuttle sheath was advanced to the left
subclavian stenosis, a Rosen wire was then placed in the axillary
artery. A 5.0 mm balloon was advanced to the subclavian and inflated to
6 atmospheres for 30 seconds with 30% residual, good flow, no evidence
of dissection or perforation, improved flow into the vertebral and
mammary arteries. Next, a 6.0 x 30 mm Assurant Cobalt iliac over-the-
wire stent was advanced to the left subclavian stenosis and deployed
just proximal to the vertebral artery at 12 atmospheres. There was 30%
residual in proximal portion of the stent. No significant residual in
the ostium or proximal portion of the stent. Next, a 5.0 x 40 balloon
was advanced into the stent, inflated to 17 atmospheres for 30 seconds
x2 with continued residual. Next, a 6.0 x 20 mm balloon was advanced to
the stent, inflated to 12 atmospheres with less than 20% residual, good
flow. Given large diameter, good stent apposition, and the risk of
possible dissection and further dilation, it was felt best to leave as a
good result. Equipment was removed, sheath exchanged for a 6-French
short sheath, to be pulled when the ACT is less than 160 seconds per
protocol. Note, the patient had good 4+ radial pulse at the end of
procedure.
IMPRESSION
1. Severe left subclavian stenosis, status post revascularization with a
6 mm x 30 mm Assurant Cobalt iliac stent with good result.
2. Severe ostial left common carotid stenosis.
3. Mild to moderate 50% internal carotid stenosis on the left.
TECHNIQUE: Informed consent was obtained. The patient was taken to the
catheterization lab. A 6-French sheath was started in the right common
femoral artery using modified Seldinger technique. A pigtail catheter
was advanced to the ascending arch, and ascending aortic arch
angiography was obtained. Catheter pulled back and exchanged for an H1
catheter and engaged the left subclavian. Left subclavian angiography
was obtained. Catheter exchanged for a Judkins right 4.0 catheter,
engaged the left common carotid artery. Angiography was obtained as well
as cerebral angiography. Catheter was pulled back, noted significant,
greater than 50 mm gradient with crossing that ostial carotid stenosis.
Next, percutaneous intervention as below. After that, equipment removed,
sheath sewn in place, to be pulled when the ACT is less than 160 seconds
per protocol.
HEMODYNAMICS: Aortic pressure 185/54. Closing pressure 149/60.
ANGIOGRAPHY: Ascending arch with significant heavy calcium deposition,
a type 3 aortic arch. Brachiocephalic artery without significant
stenosis. Right common carotid not imaged. Left common carotid with
ostial 80% severe stenosis. Left internal carotid with only 50%, mild to
moderate stenosis. Left anterior cerebral arteries suboptimally
visualized. Left middle cerebral artery without obvious cutoff.
Left subclavian with long heavy calcium, stenosis 90%.
PERCUTANEOUS INTERVENTION: Adjunctive heparin given to reduce major
adverse cardiac events after the 5-French sheath was swapped out for a 6-
French Shuttle sheath. Shuttle sheath was advanced to the left
subclavian stenosis, a Rosen wire was then placed in the axillary
artery. A 5.0 mm balloon was advanced to the subclavian and inflated to
6 atmospheres for 30 seconds with 30% residual, good flow, no evidence
of dissection or perforation, improved flow into the vertebral and
mammary arteries. Next, a 6.0 x 30 mm Assurant Cobalt iliac over-the-
wire stent was advanced to the left subclavian stenosis and deployed
just proximal to the vertebral artery at 12 atmospheres. There was 30%
residual in proximal portion of the stent. No significant residual in
the ostium or proximal portion of the stent. Next, a 5.0 x 40 balloon
was advanced into the stent, inflated to 17 atmospheres for 30 seconds
x2 with continued residual. Next, a 6.0 x 20 mm balloon was advanced to
the stent, inflated to 12 atmospheres with less than 20% residual, good
flow. Given large diameter, good stent apposition, and the risk of
possible dissection and further dilation, it was felt best to leave as a
good result. Equipment was removed, sheath exchanged for a 6-French
short sheath, to be pulled when the ACT is less than 160 seconds per
protocol. Note, the patient had good 4+ radial pulse at the end of
procedure.
IMPRESSION
1. Severe left subclavian stenosis, status post revascularization with a
6 mm x 30 mm Assurant Cobalt iliac stent with good result.
2. Severe ostial left common carotid stenosis.
3. Mild to moderate 50% internal carotid stenosis on the left.