This 71-year-old female with history of coronary disease status post multivessel stenting in the past who is presenting with combination symptoms of left-sided chest discomfort as well as left arm claudication with neurologic complain of numbness at rest. Workup showed severe left subclavian stenosis. She was referred for coronary angiogram as well as left subclavian angiogram and stenting. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 10:55 AM and monitoring period Ended 11:55 AM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery. Cardiac catheterization was performed using the usual catheters.
Finding:
1: The left main is angiographically normal.
2: The left anterior descending artery is a large vessel that supplies 2 diagonal branches and multiple septal branches. The previous inserted stent in its proximal to mid part is widely patent. There is no significant disease otherwise
3: Left circumflex: The left circumflex artery is a nondominant vessel although large, a previously inserted stent in its proximal part is widely patent. There is mild disease otherwise.
4: Right coronary artery: The right coronary artery is a large dominant vessel. The previously inserted stent proximally is patent with mild in-stent restenosis. There is diffuse multiple areas of 20-30% stenosis.
5: Left heart catheterization showed normal left ventricular end-diastolic pressure
6: Left subclavian angiogram showed more than 90% heavily calcific subclavian stenosis in the proximal part of the left subclavian artery. There is no left vertebral artery that can be visualized. The left internal mammary artery is patent.
7: Selective innominate angiogram showed a patent innominate artery and a right common carotid artery. The origin of the right subclavian artery has 70% calcific stenosis.
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Impression:
1. Patent left anterior descending artery, left circumflex artery and right coronary artery stents and no progression of disease otherwise
2. Severe stenosis in the origin of the left subclavian artery and moderate to severe stenosis in the right subclavian artery as it takes off from the innominate artery
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Plan: Proceed with intervention to the left subclavian artery
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Intervention:
The JR4 was used to intubate the origin of the left subclavian artery. A Magic torque wire was used to cross into the distal left subclavian artery. The 5 French sheath was then removed and exchanged for a 6 French shuttle sheath that was positioned in the ostium of the left subclavian artery. The severe stenosis was predilated with a 6 x 20 mm balloon however with more than 50% residual stenosis and significant gradient. The area was then treated with an 8 x 27 mm balloon expandable stent and postdilated with a 9 x 20 mm balloon with excellent result and no residual stenosis.
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Final impression:
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1. Patent left anterior descending artery, left circumflex artery and right coronary artery stents and no progression of disease otherwise
2. Severe stenosis in the origin of the left subclavian artery and moderate to severe stenosis in the right subclavian artery as it takes off from the innominate artery. The left subclavian artery was successfully treated with insertion of 8 x 27 balloon expandable stent with no residual stenosis
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I am thinking of cpt 93459,37236-lft or should I do 37225? also
thanks in advance
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