Acute inferior wall ST elevation myocardial infarction.
CLINICAL HISTORY
Mr. Clough is an 87 years old man with a medical history apparently significant
for diabetes and pneumonia. He presented by ambulance earlier today to the
Kent General Hospital with complaints of chest pain. His electrocardiogram
revealed ST segment elevations involving the inferior leads concerning for an
acute evolving inferior wall myocardial infarction. A heart alert was called
and I was asked to evaluate the patient emergently for cardiac catheterization.
We confirmed the presence of ST elevations and symptoms consistent with an
acute myocardial infarction, so the patient was transferred emergently to the
cardiac catheterization laboratory for coronary angiography and possible
intervention.
TECHNIQUE
After obtaining consent, the patient was prepped and draped in the usual
fashion. Approximately 10 milliliters of two percent Lidocaine anesthesia was
administered to the right groin prior to placement of the arterial sheath.
Under fluoroscopic guidance and using the modified Seldinger technique, a six
French arterial sheath was placed without difficulty into the right femoral
artery. We then proceeded with coronary angiography utilizing hand injections
of Visipaque contrast due to renal insufficiency through six French FL4, six
French diagnostic FL4 and a JR4 guide catheter. After the completion of the
interventional procedure, we also performed left heart catheterization. For
purposes of completeness, the left heart catheterization findings will be
described here.
FINDINGS
1. The left ventricular pressure was 185/20 millimeters of mercury. The
aortic pressure was 185/56 millimeters of mercury. There was diffuse moderate
calcification of the entire coronary tree.
2. The left main is a large vessel which bifurcates into the left anterior
descending and left circumflex branches. There is osteal 30 percent disease in
the left main without dampening of the pressure on catheter engagement.
3. The left anterior descending is a large vessel which wraps the coronary
apex and gives rise to two to three diagonal branches of significance. Again,
there is moderate calcification of the proximal to mid vessel. In the proximal
vessel there is smooth 30 percent disease. In the mid vessel beyond the second
diagonal branch there is a lengthy area of 70 to 75 percent stenosis with mild
patchy disease beyond. The first diagonal branch is small to moderate in
caliber and has proximal 80 percent disease. The second diagonal branch is
similar in size and has no significant disease.
4. The left circumflex is a large, anatomically nondominant vessel which, for
all intents and purposes, gives rise to two major obtuse marginal branches. In
the proximal left circumflex there is smooth 30 percent disease. In the mid
vessel before the origin of a large second obtuse marginal branch, there is a
second area of disease of approximately 60 percent severity. The first obtuse
marginal branch is medium in caliber and free of disease. The second obtuse
marginal branch is large in caliber and has patchy 30 percent disease.
5. The right coronary artery is a large, anatomically dominant vessel which
is 100 percent occluded in its proximal segment, with TIMI Grade 0 flow beyond.
There is minimal collateralization of a diseased PEA from the left coronary
system.
After identification of acute occlusion of the right coronary artery, we went
about attempting percutaneous intervention. The existing six French sheath was
maintained in place. Heparin at a dose of 5000 units by intravenous bolus was
administered to achieve an activated clotting time in excess of 200 seconds.
Later during the procedure, due to a large thrombus burden in the right
coronary artery, Integrilin by intravenous single bolus and infusion at renal
dosing, was administered. The right coronary artery had already been
selectively engaged initially utilizing a six French JR4 guide catheter. We
then obtained a 180 centimeter Asahi Prowater straight wire which we initially
attempted to advance beyond the point of occlusion. Although we were able to
advance this wire beyond the point of occlusion, we were unable to advance it
beyond a bend in the mid vessel despite the use of an undilated 1.5 by 8
millimeters Emerge balloon for back up. We made multiple attempts and,
unfortunately, lost guide catheter position. We made further attempts with the
use of a whisper wire but again were unsuccessful. At this point in time, we
decided to change our strategy. We removed the JR4 guide catheter and obtained
a six French IMA guide catheter to allow for extra back up. We then obtained a
0.14 inch Asahi Miracle Brothers wire. With some difficulty, we were able to
successfully advance it into the distal right coronary artery beyond the bend
in the mid vessel. We then performed multiple predilatations utilizing a 1.5
by 6 millimeters mini Trek balloon times multiple overlapping inflations.
Unfortunately follow-up angiography revealed no change in the occlusion in the
right coronary artery. We then elected to perform further predilatation. This
time, we obtained a 2.0 by 12 millimeters Mini Trek balloon and performed
multiple overlapping inflations from the early distal vessel back to the
proximal vessel. Follow-up angiography did transiently reveal re-establishment
of flow into the distal right coronary artery with what appeared to be a large
thrombus burden just prior to the distal bifurcation, perhaps also with flow
limiting dissection in the mid portion of the right coronary artery. This was
followed on repeat angiography with reocclusion of the right coronary artery
We then decided to perform further predilatation. In this case, we obtained a
2.0 by 30 millimeters Emerge balloon and performed multiple overlapping
inflations of the proximal, mid and distal vessel using this balloon up to 12
atmospheres of pressure times one minute at a time, times multiple overlapping
inflations. Follow-up angiography after 200 micrograms of intracoronary
nitroglycerin revealed resumption of TIMI Grade II-III flow into the distal
right coronary artery branches which constituted a small to moderate size
posterior descending and posterior lateral arcade. The area of thrombus had
improved but there was clearly still disease throughout. We then elected to
perform stenting of this vessel. By this point, we had exchanged the Asahi
Miracle Brothers wire for a standard Asahi wire and then obtained a second
Asahi wire for back up and as a buddy wire. We then performed stenting of the
right coronary artery from just before the distal bifurcation to the ostium of
the vessel utilizing from distal to proximal 2.5 by 28 millimeters, 2.75 by 28
millimeters, 2.75 by 28 millimeters, 2.75 by 23 millimeters, and 2.75 by 12
millimeters multi link mini vision stents. Follow-up angiography after stent
deployment revealed TIMI Grade III flow throughout the right coronary artery
with evidence of a flow limiting lesion in the posterior descending branch in
an area that was too small to allow for percutaneous intervention. We,
therefore, decided to medically manage this area. We did, however, perform post
dilatation of the entirety of the stented segment utilizing a 2.75 by 15
millimeters NC Quantum Apex balloon deployed over multiple overlapping
inflations from distal to proximal from 16 all the way up to 22 atmospheres of
pressure. Follow-up angiography after stent deployment and post dilatation
revealed an excellent angiographic result with no residual stenosis and no
evidence of proximal to distal edge dissection edge dissection, thrombosis or
spasm. There was TIMI Grade III flow in the vessel and the patient's chest
pain had practically resolved. We, therefore, elected to conclude the
angioplasty procedure. The coronary guidewires were removed and final
angiography revealed a stable appearance of the right coronary artery. We then
concluded the angiographic procedure as well.
Nonselective injection of the right ileofemoral system revealed acceptable
position of the arterial sheath in the distal right common femoral artery above
the common femoral bifurcation. There was no angiographic evidence of disease
at the site of sheath insertion and as such, a six French Angio-Seal was
deployed for hemostasis. The patient was then transferred to the recovery area
in stable condition. Of note, the patient did have intermittent atrial flutter
with a controlled ventricular response competing with sinus rhythm and two to
one AV conduction throughout the case. At the end of the case, however, the
patient was back in sinus rhythm with 2 1 AV conduction.
IMPRESSION
1. Mildly elevated LVEDP with severe systemic hypertension.
2. Severe mid left anterior descending disease.
3. Moderate left circumflex disease.
4. Acute occlusion of right coronary artery status post recannulization
angioplasty and bare metal stenting times five.
5. Status post Angio-Seal placement.
PLAN
Aspirin for life.
Plavix indefinitely.
Integrilin times 18 hours.
Aggressive risk factor modification including an echocardiogram and serial
cardiac enzymes.
Other plans will depend upon the patient's clinical course.
thanks in advance
i was thinking of 93458-xu, c9606,c9600-rc since i am hospital coder
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need help with coding baremetal stent
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