I need help with selective and nonselective coding. My doctor performed the following:
GENERAL DETAILS:
· Procedure Name 1. Aortogram
2. Left subclavian angiography
3. Left common carotid angiography
4. Right common carotid angiography
5. Bilateral cerebral angiography
6. Right upper extremity angiography
7. Conscious sedation for 40 minutes
· Indication(s) High risk for CEA and suspected asymptomatic severe left carotid stenosis via duplex US
PROCEDURE DETAILS:
Patient with a history CAD with previous CABG who had a recent syncopal episode and was found to have suspected severe left carotid stenosis. Due to his elevated risk of having carotid endarterectomy angiography was undertaken to assess for viability of a carotid stent. After informed written consent was obtained from the patient which included a discussion of possible risk, possible complications, and alternatives to therapy, he elected to proceed.
The patient was brought to the cardiac catheterization lab where he was prepped and draped in usual sterile fashion. 2% lidocaine was used to infiltrate the right wrist region for local anesthesia. A 6 French slender sheath was inserted into the right radial artery using a modified Seldinger technique in the usual manner without incident. An 035 inch J-tip guidewire was attempted to be advanced with resistance and therefore right upper extremity angiography was performed to assess the radial artery. An 0.014"x190cm BMW wire was used to advance a pigtail catheter to the ascending aorta. Power injection aortography was performed in an LAO projection. Over an exchange length wire the pigtail catheter was removed and a 5 French Simmons 1 Sidewinder catheter was inserted over the wire and used to cannulate the left subclavian artery and angiography was performed. Then the Simmons catheter was used to cannulate the left common carotid artery. Carotid angiography was performed in multiple projections followed by left cerebral angiography and a Townes and lateral projections. The Simmons catheter was then used to cannulate the right common carotid artery and carotid angiography was performed in multiple projections. This was followed by right cerebral angiography and a Townes and lateral projections. Over the wire all catheters and wires were removed without incident. Air in a TR band was used to place patent hemostasis of the right radial artery and remove the 6 French slender sheath.
Procedural findings:
Aorta: Type II aortic arch with mild diffuse disease and calcification and no critical disease.
Left subclavian artery: 30-40% stenosis with calcification and no critical disease.
Left common carotid artery: Mild luminal irregularities without critical disease
Left internal carotid artery: 90-95% calcified, ulcerative stenosis with mild tortuosity distally.
Left external carotid artery: Luminal irregularities without critical disease.
Left cerebrals: Patent left MCA vasculature with incomplete ACA likely originating from the right
Right common carotid artery: Luminal irregularities throughout no critical disease.
Right internal carotid artery: Mild proximal 10-20% stenosis with heavy calcification
Right external carotid artery: 20-30% ostial stenosis with luminal irregularities and no critical disease
Right cerebrals: Patent MCA and ACA vasculature with distribution of the left ACA
Impressions:
1. Type II aortic arch with mild diffuse disease and calcification. Left vertebral originates from aortic arch between the origin of the left subclavian and left common carotid.
2. Severe left internal carotid artery stenosis
3. Patent cerebral vasculature
4. Patent hemostasis of the right radial artery using air in a TR band
Recommendations:
1. Routine post cerebral angiography care
2. IV fluid hydration
3. Initiate clopidogrel and continue aspirin for carotid stenting
4. Resume hydralazine for BP control with holding 48 hours prior to carotid stenting
5. Coordination for right carotid artery stenting at Providence Hospital in near future
6. Anticipate discharge in 2-3 hours if no unforeseen complications
Any help is very appreciated.
Thank you
GENERAL DETAILS:
· Procedure Name 1. Aortogram
2. Left subclavian angiography
3. Left common carotid angiography
4. Right common carotid angiography
5. Bilateral cerebral angiography
6. Right upper extremity angiography
7. Conscious sedation for 40 minutes
· Indication(s) High risk for CEA and suspected asymptomatic severe left carotid stenosis via duplex US
PROCEDURE DETAILS:
Patient with a history CAD with previous CABG who had a recent syncopal episode and was found to have suspected severe left carotid stenosis. Due to his elevated risk of having carotid endarterectomy angiography was undertaken to assess for viability of a carotid stent. After informed written consent was obtained from the patient which included a discussion of possible risk, possible complications, and alternatives to therapy, he elected to proceed.
The patient was brought to the cardiac catheterization lab where he was prepped and draped in usual sterile fashion. 2% lidocaine was used to infiltrate the right wrist region for local anesthesia. A 6 French slender sheath was inserted into the right radial artery using a modified Seldinger technique in the usual manner without incident. An 035 inch J-tip guidewire was attempted to be advanced with resistance and therefore right upper extremity angiography was performed to assess the radial artery. An 0.014"x190cm BMW wire was used to advance a pigtail catheter to the ascending aorta. Power injection aortography was performed in an LAO projection. Over an exchange length wire the pigtail catheter was removed and a 5 French Simmons 1 Sidewinder catheter was inserted over the wire and used to cannulate the left subclavian artery and angiography was performed. Then the Simmons catheter was used to cannulate the left common carotid artery. Carotid angiography was performed in multiple projections followed by left cerebral angiography and a Townes and lateral projections. The Simmons catheter was then used to cannulate the right common carotid artery and carotid angiography was performed in multiple projections. This was followed by right cerebral angiography and a Townes and lateral projections. Over the wire all catheters and wires were removed without incident. Air in a TR band was used to place patent hemostasis of the right radial artery and remove the 6 French slender sheath.
Procedural findings:
Aorta: Type II aortic arch with mild diffuse disease and calcification and no critical disease.
Left subclavian artery: 30-40% stenosis with calcification and no critical disease.
Left common carotid artery: Mild luminal irregularities without critical disease
Left internal carotid artery: 90-95% calcified, ulcerative stenosis with mild tortuosity distally.
Left external carotid artery: Luminal irregularities without critical disease.
Left cerebrals: Patent left MCA vasculature with incomplete ACA likely originating from the right
Right common carotid artery: Luminal irregularities throughout no critical disease.
Right internal carotid artery: Mild proximal 10-20% stenosis with heavy calcification
Right external carotid artery: 20-30% ostial stenosis with luminal irregularities and no critical disease
Right cerebrals: Patent MCA and ACA vasculature with distribution of the left ACA
Impressions:
1. Type II aortic arch with mild diffuse disease and calcification. Left vertebral originates from aortic arch between the origin of the left subclavian and left common carotid.
2. Severe left internal carotid artery stenosis
3. Patent cerebral vasculature
4. Patent hemostasis of the right radial artery using air in a TR band
Recommendations:
1. Routine post cerebral angiography care
2. IV fluid hydration
3. Initiate clopidogrel and continue aspirin for carotid stenting
4. Resume hydralazine for BP control with holding 48 hours prior to carotid stenting
5. Coordination for right carotid artery stenting at Providence Hospital in near future
6. Anticipate discharge in 2-3 hours if no unforeseen complications
Any help is very appreciated.
Thank you
Last edited: