PROCEDURE PERFORMED:
1. Arch aortography.
2. Selective carotid angiography of the left internal carotid artery.
3. Nonselective of the right internal carotid artery.
4. Distal embolic protection and balloon angioplasty of the left common carotid
artery. No stent was placed.
5. MynxGrip successfully used in the left femoral artery with hemostasis.
6. Ultrasound for vascular access.
7. Supervision and interpretation of above.
8. Modifier 22 for mental stress/difficult case.

INDICATION:
The patient is a 71-year-old female with significant Hollenhorst plaque noted
in her eye with further evaluation of the carotid arteries noted severe at
least 70% calcific right common carotid artery stenosis, as well as 90% left
common carotid artery stenosis. Informed and witnessed signed and placed in
the patient’s medical record. The patient understood the risks, benefits, and
alternatives of procedures, and wished to proceed. Risks include, but are not
limited to stroke, myocardial infarction, renal failure, bleeding, limb loss,
and death.

DESCRIPTION OF PROCEDURE:
The patient was brought to the cardiac catheterization laboratory in the
fasting state. Both groins were prepped and draped in sterile fashion. 2%
lidocaine was infused in the patient’s left inguinal area for local anesthesia.
Using modified Seldinger technique, ultrasound for vascular access, a 6-French
side-arm sheath successfully placed in the left femoral artery. Given the
tortuosity, this was later changed for a 45 cm destination 6-French sheath.
However, prior to this, a pigtail catheter was placed in the area of the
ascending aorta and arch angiography was performed using digital subtraction.

Attempt to cannulate with Simmons 2 catheter, which did not cannulate
ultimately was a JR4 catheter that was able to get near selective images of the
right innominate artery. However, could not give enough contrast to opacify
the carotid bifurcation.

I focused on the left internal carotid artery, left common carotid artery with
a JR4 was able to cannulate into the left common carotid artery ostium. An
angiography performed in multiple orthogonal views.

I proceeded to intervention.

Heparin was used during the case. ACT was greater than 250 seconds.

Initial Nav6 distal embolic protection was placed at the level of the distal
common carotid artery.

A run-through wire was also placed there for additional support. Balloon
angioplasty was performed with a Viatrac 5.0 balloon up to nominal atmospheres.
However, there was difficulty given the sheath size, as well as the type of
balloon expandable stent. I wanted with the Omnilink could not find one that
have the 135 cm shaft rather than 80 cm shaft given that my guide was 100 cm
long. Therefore ultimately after trying several different catheters and
balloon and stents, ultimately aborted the procedure. We will reschedule for
an Omnilink with 135 cm shaft in the few days if possible. There were no
complications. I was present and scrubbed throughout the case.

RESULTS:
1. Arteriography: Arch aortography demonstrates a type 3 arch with severe
calcification noted especially at the level of the right innominate artery.
2. Right innominate artery: Right innominate artery is severely calcific with
approximately a 90% lesion noted at the level of the ostial proximal portion.
3. Left common carotid artery: Left common carotid artery contains a focal 90%
lesion noted in the ostial prox portion. The carotid artery itself otherwise
is mild disease only and the common right internal carotid artery only has
luminal irregularities.
4. Cerebral angiography. Cerebral angiography demonstrates widely patent
anterior cerebral artery and middle cerebral artery.

INTERVENTION:
1. Diameter of stenosis pre was 90%, post was 0% with only mild calcification
noted in the proximal common carotid artery on the left. Balloon inflated with
a 5.0 x 20 mm Viatrac up to 7 atmospheres.
2. Diameter of stenosis pre was 90%, post was 70%.

IMPRESSION:
1. Significant bilateral stenosis noted in the common carotid arteries, 90%
calcific on the right, 90% less calcific on the left.
2. Status post balloon angioplasty with a 5.0 Viatrac for the left common
carotid artery lesion with residual stenosis approximately 70%.

Codes:
37215
76937-26
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