Hi All…could someone let me know what they are thinking for codes/mods for this since it the procedure wasn’t completed? Thank you!

Emergency left heart catheterization with measurement of left ventricular end-diastolic
pressure, selective right and left coronary angiography, PTCA of mid-vessel RCA lesion,
unable to open or cross the mid-vessel lesion to reach the culprit lesion, although we did
re-establish TIMI-3 flow with a guidewire.
CLINICAL DATA:
Patient is a 75-year-old female with known coronary artery disease. She had an
anterior wall infarct in 2011. She underwent PCI and placement of 2 stents in her LAD
with good results. She is noncompliant, stopped all her medications, has not followed up.
At the time of her original cardiac catheterization her ejection fraction was estimated
in the 35% range with anterior wall motion abnormality and she was felt to have a 90%
residual lesion, which was apparently scheduled to be treated as a staged procedure.
However, the patient never followed up. She began having chest pain and nausea today
approximately 9 hours prior to presentation to emergency room where an EKG demonstrated
subtle ST-segment elevation in lead 3 and AVF with reciprocal depression in V2 and lateral
leads. The patient is taken urgently to the cardiac catheterization laboratory. The
diagnostic procedure is performed from the right groin using modified Seldinger technique
and a 6-French multipurpose catheter.
HEMODYNAMIC DATA:
1. Arterial pressure 200/70, mean 125.
2. LV pressure 200 with an LVEDP of 32.
3. Left ventricular angiography is not performed because of elevated left ventricular
end-diastolic pressure.
CORONARY ANGIOGRAPHY:
Coronary angiography is performed in multiple projections:
A. The left main coronary artery is a moderate-sized vessel. There is mild
nonobstructive plaquing in the distal aspect of the left main coronary artery, but no
significant disease is noted. The left main ends in a bifurcation and arises from the
left cusp.
B. The circumflex is a moderate size nondominant vessel. There is mild nonobstructive
plaquing noted in the proximal circumflex. No significant disease is noted.
C. The left anterior descending artery is patient’s previous culprit vessel. There are 2
patent stents in the proximal portion of left anterior descending artery with minimal
in-stent restenosis. In the distal aspect of the left anterior descending artery there is
an eccentric plaque of approximately 50%.
D. The right coronary artery is the patient’s current culprit vessel. The right coronary
artery is severely and diffusely diseased. There appears to be mild amount of calcium.
The origin of the right coronary artery is patent immediately supplies a very large right
ventricular branch, which also gives rise to the SA nodal branch. As the right coronary
artery continues it is very small, there is a lesion in the proximal portion of at least
80% to 90%. At the acute margin the right coronary artery is totally occluded. The RV
branch is also severely diseased in its mid-segment.
IMPRESSIONS:
1. Acute inferior wall myocardial infarction.
2. Elevated left ventricular end-diastolic pressure.
3. Normal sinus rhythm.
4. Totally occluded native right coronary artery, which appears to be dominant vessel.
There are some intercoronary collaterals from the septal arcade of the LAD to the right
coronary artery and posterolateral ventricular branch.
COMMENTS:
Plans for ad hoc angioplasty had been made. We selected a JR4 guiding catheter. We
placed 0. 014 wire and a 2 x 20 Emerge balloon. The patient had been given 10000 units of
heparin IV push in the emergency room, was given an additional 5000 units of heparin at
the start of the PCI. We were able to wire the vessel and penetrate the thrombus in the
distal right coronary artery with the use of 2-0 balloon. I then attempted to advance the
2-0 balloon, however we could not advance the balloon past the mid-portion of the right
coronary artery and certainly it did not reach the area of total occlusion. We were able
to take subsequent angiograms and there was concentric 99% diameter stenosis in the distal
right coronary artery proximal to the origin of the posterior descending artery. We did
establish TIMI-3 flow in this vessel. We attempted multiple times to cross the lesion
giving intracoronary nitroglycerin. We downsized to a 1.2 x 20 balloon. We did several
inflations in the mid-right coronary artery proximal to the lesion. However, we were
still unable to advance the balloon catheter past the mid-vessel. It was clear we would
never be able to stent the culprit lesion. After trying multiple guiding catheters
including JR4, JR4 with side holes, AL2, and an AL2 with side holes. We abandoned the
procedure. Repeat angiograms demonstrated TIMI-3 flow into the distal right coronary
artery. There was some spasm in the right ventricular branch, which was gradually
relieved by the time the patient left the laboratory. At this point in time, I felt that
surgery may be an option for the patient. We took a diagnostic JR4 catheter, and we did a
selective left internal mammary angiogram. The vessel appears to be adequate for use as
in situ graft however, there was 75% diameter stenosis involving the left subclavian
artery proximal to the origin of the LIMA. The patient’s left vertebral artery also
arises from the very proximal portion of the left subclavian artery near the transverse
aortic arch origin of the left subclavian vessel. At this point in time, the procedure
was terminated. We started the patient on heparin drip. We secured the sheath. We will
consult cardiovascular surgery. Graftable vessels included the distal right coronary
artery, the right ventricular branch which has severe disease in its mid-portion and
possibly the
left anterior descending artery. An echocardiogram will be ordered to evaluate the
patient’s left ventricular ejection fraction.