OPENSHAW
Guru
Diagnostic Coronary Angiogram
Pre-Procedure Diagnosis: CAD, + troponin, onging Angina, s/p ACB
Post-Procedure Diagnosis: Same
Procedure performed: Selective coronary angiogram of the left main (LM) and right coronary artery (RCA). A left ventriculogram was not performed. Selective LIMA injection, selective bypass graft injection, sub selective RIMA injection, selective subclavian and inominante arteriograms
Anesthesia Used: IV versed and fentanyl, local 2% lidocaine
Blood Loss: 40 mL
Condition: stable
IV Contrast Used: 250 mL
Complications: none
Procedure and Findings in Detail: The procedure was described to the patient including benefits, risks, and alternatives to the procedure. The patient confirmed understanding. The patient signed the informed consent. He was brought into the cath lab. The bilateral groins were prepped in a sterile fashion, and a sterile drape was placed over the patient.
The right common femoral artery (CFA) was palpated and the region above the artery was anesthetized with 2% local lidocaine. A Cook needle was used to access the right CFA. The wire was visualized under fluoroscopy ascending into the common iliac artery. A 6 French sheath was placed over the wire without difficulty in the normal form and fashion.
A 6 Fr diagnostic JL4 was placed in the ascending aorta directed by a J wire. The J wire was removed, the catheter aspirated to remove any air and flushed with normal saline. The diagnostic catheter engaged the left main without difficulty. The diagnostic evaluation revealed the following:
Left main: no disease
LAD: proximal 50% ulcerated lesion and after D2 40-50% lesion
Diagonals: patent, D2 not seen
Circumflex: From RCA, nonocclusive disease
Obtuse marginals: nonocclusive disease
The diagnostic catheter used for the left coronary was removed from the descending aorta over the J wire. A 6 French diagnostic JR4 was placed over the wire and guided to the ascending aorta. The J wire was removed. The catheter was aspirated and flushed with normal saline. The diagnostic evaluation revealed the following:
RCA: tortuous, large vessel mid 50% and distal 70% with haziness at this site
PDA: patet nonocclusive disease
PLV: nonocclusive disease.
We the removed the RCA catheter over the wire and exchanged to a LIMA catheter and we used a wooly wire to enter the left subclavian. We then attempted to engage the right inominante but were unable to advance the IMA catheter. We then attempted an AR1 but again were unsuccessful. We also attempted using a seeker catheter over a 0.018 wire to provide support and guide the AR1 but were unable to engage the R inominante due to the angulation. Hence we performed a sub selective angiogram.
LIMA: atretic
RIMA: nonselective atretic
Inominante arteriogram nonocclusive disease
Subclavian: nonocclusive disease
Radial artery graft D2 patent
We then removed the AR1 and exchanged it for a 5Fr pigtail over the wire. We crossed the AV and were able to obtain LV EDP and pressures.
LCH: no LV gram, no gradient on pull back. EDP was 5
The patient was in hemodynamically stable condition throughout entirety of the procedure. The sheath was removed and manual pressure was held for 20 mins., and the patient will be on bed rest for 6 hours. Aggressive medical management for CAD and associated risk factors will continue and there are medication changes consisting of the following: addition of plavix, stopping heparin, continue nitro gtt. Patient will return to the inpatient ward for further management.
Summary:
CAD, ulcerated LAD plaque
RCA with hazy distal plaque very tortous
LIMA and RIMA artertic, patent radial artery graft to D2
Above report seen and i agree
Plan:
Add plavix (loaded 300 in cath lab)
Continue nitro
Stop hep gtt
Aggressive medical managment
Would this be coded as:
93459-26, dx. 414.00, 413.9, 410.70, V45.81
93567, dx. 414.00, 413.9, 410.70, V45.81
36225, dx. 447.1
Thank you!
Pre-Procedure Diagnosis: CAD, + troponin, onging Angina, s/p ACB
Post-Procedure Diagnosis: Same
Procedure performed: Selective coronary angiogram of the left main (LM) and right coronary artery (RCA). A left ventriculogram was not performed. Selective LIMA injection, selective bypass graft injection, sub selective RIMA injection, selective subclavian and inominante arteriograms
Anesthesia Used: IV versed and fentanyl, local 2% lidocaine
Blood Loss: 40 mL
Condition: stable
IV Contrast Used: 250 mL
Complications: none
Procedure and Findings in Detail: The procedure was described to the patient including benefits, risks, and alternatives to the procedure. The patient confirmed understanding. The patient signed the informed consent. He was brought into the cath lab. The bilateral groins were prepped in a sterile fashion, and a sterile drape was placed over the patient.
The right common femoral artery (CFA) was palpated and the region above the artery was anesthetized with 2% local lidocaine. A Cook needle was used to access the right CFA. The wire was visualized under fluoroscopy ascending into the common iliac artery. A 6 French sheath was placed over the wire without difficulty in the normal form and fashion.
A 6 Fr diagnostic JL4 was placed in the ascending aorta directed by a J wire. The J wire was removed, the catheter aspirated to remove any air and flushed with normal saline. The diagnostic catheter engaged the left main without difficulty. The diagnostic evaluation revealed the following:
Left main: no disease
LAD: proximal 50% ulcerated lesion and after D2 40-50% lesion
Diagonals: patent, D2 not seen
Circumflex: From RCA, nonocclusive disease
Obtuse marginals: nonocclusive disease
The diagnostic catheter used for the left coronary was removed from the descending aorta over the J wire. A 6 French diagnostic JR4 was placed over the wire and guided to the ascending aorta. The J wire was removed. The catheter was aspirated and flushed with normal saline. The diagnostic evaluation revealed the following:
RCA: tortuous, large vessel mid 50% and distal 70% with haziness at this site
PDA: patet nonocclusive disease
PLV: nonocclusive disease.
We the removed the RCA catheter over the wire and exchanged to a LIMA catheter and we used a wooly wire to enter the left subclavian. We then attempted to engage the right inominante but were unable to advance the IMA catheter. We then attempted an AR1 but again were unsuccessful. We also attempted using a seeker catheter over a 0.018 wire to provide support and guide the AR1 but were unable to engage the R inominante due to the angulation. Hence we performed a sub selective angiogram.
LIMA: atretic
RIMA: nonselective atretic
Inominante arteriogram nonocclusive disease
Subclavian: nonocclusive disease
Radial artery graft D2 patent
We then removed the AR1 and exchanged it for a 5Fr pigtail over the wire. We crossed the AV and were able to obtain LV EDP and pressures.
LCH: no LV gram, no gradient on pull back. EDP was 5
The patient was in hemodynamically stable condition throughout entirety of the procedure. The sheath was removed and manual pressure was held for 20 mins., and the patient will be on bed rest for 6 hours. Aggressive medical management for CAD and associated risk factors will continue and there are medication changes consisting of the following: addition of plavix, stopping heparin, continue nitro gtt. Patient will return to the inpatient ward for further management.
Summary:
CAD, ulcerated LAD plaque
RCA with hazy distal plaque very tortous
LIMA and RIMA artertic, patent radial artery graft to D2
Above report seen and i agree
Plan:
Add plavix (loaded 300 in cath lab)
Continue nitro
Stop hep gtt
Aggressive medical managment
Would this be coded as:
93459-26, dx. 414.00, 413.9, 410.70, V45.81
93567, dx. 414.00, 413.9, 410.70, V45.81
36225, dx. 447.1
Thank you!