heart cath & selective renal?

Need assistance for left heart cath w/ renal angiography, etc
Thank you for any help.
93458 26 59 (lhc)
36251 (renal?)
92928 RC...

LHC/CORONARIES W/WO LV GRAM
STENT (BMS OR DES) RC (COR)
Left subclavian angiography- EXTREMITY, UNILATERAL RT (SELECTIVE)
Right subclavian angiography- nonselective
ABDOMINAL AORTOGRAM
RENAL ANGIOGRAPHY, UNILATERAL RT
Clinical History & Appropriate Use
67-year-old with history of coronary stenting admitted with angina
pectoris in the pattern consistent with class IV
angina. She had severe central hypertension with marked discrepancy in
the left upper extremity blood pressure prompting left
subclavian angiography. I also had difficulty advancing the catheters
through the right subclavian prompting right subclavian
angiography. After finding severe peripheral arterial disease who
presents for severe hypertension, abdominal aortography was
performed to assess renovascular hypertension.
Diagnostic Procedure Details
.
The patient was prepped and draped in the standard manner. 2% lidocaine
was used for local anesthesia over the right radial
artery. The radial artery was accessed with a micro puncture needle and a
5 Fr glide sheath advanced using and over the wire
technique. Bilateral selective coronary angiography was performed with a
Tig catheter. Left heart catheterization and LV
angiography was performed with a Tig catheter.

A JL 3.5 catheter was advanced from the right radial artery and to the
aortic arch and used to selectively engage the left
subclavian artery. Angiography was performed. The jail catheter was
exchanged for a pigtail catheter was advanced into the
descending aorta at the level of the renal arteries and an abdominal
aortogram was performed. We then selectively engaged the
right renal artery with a multipurpose catheter and repeated angiography
of the right renal artery. Intervention was performed
on the right coronary artery as described below. Nonselective
angiography of the right subclavian artery was performed
utilizing the interventional guide catheter which was withdrawn from the
right coronary artery into the brachiocephalic artery
where angiography was performed. Based on findings of diagnostic catheterization, intervention was
undertaken on the RCA.
Prior to intervention, the flow in the target vessel was TIMI 3.
Angiomax was used for anticoagulation.
The guide used was a 6 French Mac 3.0 guide catheter.
The lesion was wired with a Runthrough 0.014 guidewire.
The lesion was pre-treated with a Medtronic Sprinter RX 1.5mmX 10mm
balloon followed by a Abbott Trek RX 3.0mmX 20mm
balloon.
The lesion was stented with a Abbott Xience Alpine 3.5mmX 23mm
Following the intervention, there was no residual stenosis and TIMI-3
flow.
Final angiography demonstrated no perforation, dissection or distal
embolization.
Peripheral Vascular
Angiography at the level of the renal arteries demonstrates a probable
high-grade stenosis in the right renal artery. Due to
extreme tortuosity coming from the right radial artery, it was difficult
to directly engage the origin of the right coronary artery
with a multipurpose catheter. Angiography did suggest high-grade
stenosis and further evaluation by renal duplex ultrasound
is recommended.

The left subclavian artery was selectively engaged and angiography
demonstrated occlusion of the left subclavian artery
proximal to the left vertebral artery.

The right subclavian artery was found to have an eccentric calcified
stenosis of at least 70%. There was a 20 mm gradient on
pullback across that stenosis in the right upper extremity.

heart cath & selective renal?