Any ideas on code for this? Will I have to use unlisted?
1. Sealing of a large coronary aneurysm with a vascular plug.
He was admitted to the hospital a few days ago with sepsis. He was
found to have an elevated troponin. An echo showed preserved left
ventricular function but there was suggestion of a possible abscess or
aneurysm. A transesophageal echocardiogram showed a 5 cm aneurysmal
structure with arterial communication with the left coronary system.
A CT scan also demonstrated that aneurysm measuring 5.0-5.2 cm. This
was quite a bit larger than a CT scan just a month ago where it was
not documented, but in hindsight, it was 3.7 cm at that time. A
coronary angiogram was done 2 days ago which showed that this large
aneurysm was coming off a small nipple of a left main. A surgical
consultation was obtained and he was deemed to be too high risk for
surgery. After multiple discussions about alternative treatments, it
was decided to pursue a vascular plug.
DETAILS OF PROCEDURE: Local anesthesia was attained in the right
groin. A 6-French long sheath was placed in the right femoral artery.
An angiogram was initially done with a 5-French JL4 guide which
re-demonstrated the aneurysm after just a short 4 or 5 mm left main.
There was a very narrow neck into the aneurysm. An attempt was made
to wire this neck, but the JL guide kept backing out. We thus
switched to a 5-French EBU 3.75 guide, which seemed to have more
support. Using an over-the-wire balloon for support, we were able to
wire the aneurysm with a Grand Slam. Over this wire, we were able to
advance the 1.2 mm over-the-wire balloon which was used to modestly
dilate the neck. We then were able to advance the 5-French guide
catheter over the balloon into the aneurysm.
Now that the guide catheter was in the aneurysm, we were able to
advance a 5 mm AVP 4 plug where the first disk was deployed in the
aneurysm, the entire device was pulled back against the wall of the
aneurysm, and then the second disk was deployed in the left main.
Multiple pushing and pulling maneuvers were performed to make sure
that the device was stable in this position. The device was then
released. An angiogram was then done through the guide catheter,
which appeared to show no further flow going into the left main or
aneurysm.
A LIMA angiogram was then performed, which did not show any flow
coming back from the LAD back into the aneurysm.
A transesophageal echo was done, reported separately. It showed that
the aneurysm was already 70% or 80% clotted off. Of note, we had
given 7000 units of Heparin at the beginning of the procedure.
The sheath was removed and hemostasis was obtained using a StarClose
device.
1. Sealing of a large coronary aneurysm with a vascular plug.
He was admitted to the hospital a few days ago with sepsis. He was
found to have an elevated troponin. An echo showed preserved left
ventricular function but there was suggestion of a possible abscess or
aneurysm. A transesophageal echocardiogram showed a 5 cm aneurysmal
structure with arterial communication with the left coronary system.
A CT scan also demonstrated that aneurysm measuring 5.0-5.2 cm. This
was quite a bit larger than a CT scan just a month ago where it was
not documented, but in hindsight, it was 3.7 cm at that time. A
coronary angiogram was done 2 days ago which showed that this large
aneurysm was coming off a small nipple of a left main. A surgical
consultation was obtained and he was deemed to be too high risk for
surgery. After multiple discussions about alternative treatments, it
was decided to pursue a vascular plug.
DETAILS OF PROCEDURE: Local anesthesia was attained in the right
groin. A 6-French long sheath was placed in the right femoral artery.
An angiogram was initially done with a 5-French JL4 guide which
re-demonstrated the aneurysm after just a short 4 or 5 mm left main.
There was a very narrow neck into the aneurysm. An attempt was made
to wire this neck, but the JL guide kept backing out. We thus
switched to a 5-French EBU 3.75 guide, which seemed to have more
support. Using an over-the-wire balloon for support, we were able to
wire the aneurysm with a Grand Slam. Over this wire, we were able to
advance the 1.2 mm over-the-wire balloon which was used to modestly
dilate the neck. We then were able to advance the 5-French guide
catheter over the balloon into the aneurysm.
Now that the guide catheter was in the aneurysm, we were able to
advance a 5 mm AVP 4 plug where the first disk was deployed in the
aneurysm, the entire device was pulled back against the wall of the
aneurysm, and then the second disk was deployed in the left main.
Multiple pushing and pulling maneuvers were performed to make sure
that the device was stable in this position. The device was then
released. An angiogram was then done through the guide catheter,
which appeared to show no further flow going into the left main or
aneurysm.
A LIMA angiogram was then performed, which did not show any flow
coming back from the LAD back into the aneurysm.
A transesophageal echo was done, reported separately. It showed that
the aneurysm was already 70% or 80% clotted off. Of note, we had
given 7000 units of Heparin at the beginning of the procedure.
The sheath was removed and hemostasis was obtained using a StarClose
device.