Stent Case Studies
ST‐1
INDICATION: Patient with clinical findings of subclavian steal on the left. Additionally, the
patient has a bluish discolored distal left 5th finger, suggestive of distal thromboemboli. CT
of neck confirmed high‐grade stenosis of the subclavian artery. Carotid artery duplex
demonstrated reversal of flow within the left vertebral artery.
PROCEDURE PERFORMED
1.
2.
3.
4.
5.
6.
7.
8.
Retrograde puncture of the right common femoral artery.
Catheterization of the thoracic arch.
Thoracic arch aortogram in LAO projection.
Selective catheterization of the left subclavian artery.
Left upper extremity angiogram.
Stenting of high‐grade proximal left subclavian artery stenosis.
Additional views obtained of the left subclavian artery.
IV conscious sedation.
Pre‐procedure evaluation confirmed that the patient was an appropriate candidate for
conscious sedation. Vital signs, pulse oximetry, and response to verbal commands were
monitored and recorded by the nurse throughout the procedure and the recovery period.
All medication for conscious sedation, including the doses administered was placed in the
medical record. The patient returned to baseline neurologic and physiologic status prior to
leaving the department. No immediate sedation‐related complications were noted.
Informed written consent was obtained from the patient after discussion of risks, benefits,
alternatives of the procedure. The patient expressed full understanding and agreed to
proceed forward.
The patient was placed supine on the angiographic table. The right groin was prepped and
draped in the normal sterile fashion. Puncture was made of the right common femoral
artery in a retrograde fashion using a 21‐gauge micropuncture needle. A 0.018 wire was
advanced and a 4‐French transitional coaxial dilator was placed. A 0.025 wire was advanced
followed by placement of a 5‐French pigtail catheter in the ascending aorta.
A steep LAO thoracic arch aortogram was performed. The left common carotid artery and
brachiocephalic artery share a common origin. The proximal aspect of the vessels appear
unremarkable. The origin of the left subclavian artery is widely patent. There is a significant
stenosis within the proximal left subclavian artery, as seen on CTA. There is retrograde flow
through the left vertebral artery.
Next, the left subclavian artery was catheterized and a wire was advanced into the left
subclavian artery distally. A catheter followed. A multistation left upper extremity
arteriogram was performed. The origin of the left subclavian artery is patent. The high‐
grade stenosis was again identified. The origin of the left vertebral artery demonstrates
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Page 225
moderate stenosis. The remainder of the left subclavian artery is unremarkable. The left
axillary and brachial arteries are normal in appearance. The radial and ulnar arteries are
normal in appearance. The inner osseous artery fills normally. The superficial and deep
pulmonary arches opacify with contrast agent. The common digital branches opacify
normally. There is poor filling of the lateral branch of the 5th proper digital branch as well
as the lateral 2nd proper digital branch.
Next, a 6‐French sheath was advanced to the origin of the left subclavian artery. A dedicated
angiogram was performed delineating the focal area of stenosis. A 7‐29 balloon expander
with stent was then deployed across the area of stenosis. The stent was fully deployed using
8 atmospheres of pressure. A repeat injection of contrast to the sheath demonstrated an
excellent result with resolution of the previously seen stenosis. The left vertebral artery
now fills in antegrade fashion.
At this point, procedure was terminated. Sheath, catheters and lines were removed.
Hemostasis was obtained with an Angio‐Seal device. The patient tolerated the procedure
well. There were no immediate complications.
Total fluoroscopy time was 7.5 minutes. The patient received 50 mL of Isovue‐370 and 48
mL of Visipaque 320. The patient received 4 mg Versed, 150 mcg fentanyl, 3000 units
heparin and 1 gram Ancef IV. The patient received 300 mg of Plavix p.o.
CONCLUSION: High‐grade proximal left subclavian artery stenosis corresponding to lesion
seen on CTA. There was reversal of flow seen within the left vertebral artery. This lesion
was successfully treated using a 7 mm balloon‐expandable stent with an excellent result
achieved. There is now antegrade flow within the left vertebral artery.
The remainder of the subclavian artery as well as the axillary artery, brachial artery, and
radial and ulnar arteries are normal in appearance. There is poor filling of the lateral
branches of the proper digital arteries of digits 2 and 5, which may be indicative of
thromboembolism.
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Page 226
ST‐1 Codes & Explanation
Access was gained at the right common femoral artery (36140‐bundled) and the catheter was
advanced into the ascending aorta for an arch angiogram (36221). Diagnostic angiography
was performed of the aortic arch from the injection of contrast at the aorta as noted under
findings –origins of innominate, left common carotid and subclavian (36221). Code 36200 for
catheterization of the aorta is bundled into code 36221.
The catheter was selectively advanced to the left subclavian artery, a first order vessel off of
the aorta. The most distal catheter placement was the subclavian, therefore code 36215 is
assigned. Always code selective over non‐selective from the same access site. Imaging of the
left upper extremity was also performed (75710‐59). The ‐59 is appended to 75710 to indicate
that the diagnostic angiography meets criteria for reporting at the same session as the
therapeutic intervention performed at the subclavian. Modifier ‐59 is also needed on 36215 so
it will not bundle with 36221.
The physician placed a stent across the area of stenosis in the subclavian artery (37236).
Final CPT® Codes: 36221, 36215, 37236, 75710‐59‐LT
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Page 227
ST‐2
BILATERAL RENAL ARTERIOGRAM, RIGHT RENAL ARTERY ANGIOPLASTY AND STENT
PLACEMENT
Informed consent was obtained from the patient prior to the procedure. During this
process, the procedure and potential alternatives were explained along with the intended
outcome and benefits. The risks of the procedure, including the possibility of an
unsuccessful procedure, as well as the risk of not doing the procedure were discussed.
The left groin was prepped and draped in usual sterile fashion. Using standard
interventional sterile and Seldinger technique, a 6 French sheath was introduced into the
left common femoral artery. A 5 French contra 2 catheter was introduced over the 0.035
inches 15 J wire into the abdominal aorta. 3000 units of heparin was then given
intravenously. The catheter was placed separately into each of the 3 separate renal arteries
for contrast injection and angiography. The main left renal artery appears widely patent.
The lower pole main right renal artery appears widely patent. The accessory upper pole
right renal artery is now occluded.
Using standard catheter and guidewire techniques the occlusion in the upper pole right
renal artery was crossed. The McNamara 0.018 inches wire was introduced into the distal
left renal artery using standard technique. A 6 French 45 cm bright tip sheath was then
introduced over the wire into the proximal right renal artery. Great care was utilized
throughout the procedure to monitor the position of the wire in the distal right renal artery
without movement. A Palmaz Genesis stent was then deployed in the right renal artery
across the stenosis. Balloon dilatation of the stent was performed. Multiple balloon
dilatations were performed. Good luminal contour and good flow was demonstrated. A total
of 25 cc of Visipaque 320 contrast was utilized because of a mildly elevated creatinine. The
repeat arteriogram demonstrated good luminal contour and good flow. The catheters and
wires were removed under fluoroscopic guidance. The sheath was removed from the left
groin. Good hemostasis was achieved. The patient tolerated the procedure well. The patient
was monitored in the hospital during the day and then discharged home in good condition
with instructions.
Findings: There is a right renal artery occlusion. 3000 units of heparin was given
intravenously. A successful 5 mm x 15 millimeters Palmaz Genesis stent was deployed in
the right renal artery. The stent was placed so that it extended out into the abdominal aorta.
Good luminal contour and flow was achieved. The distal branches of the right renal artery
appear patent. The main right renal artery stent appears widely patent. The main left renal
artery stent appears widely patent. If the patient's hypertension continues other options
such as surgical bypass, surgical resection or embolization to be considered.
IMPRESSION: Successful right renal artery angioplasty and stent placement.
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Page 228
ST‐2 Codes & Explanation
Access was gained at the left common femoral artery (36140) and the catheter was advanced
into three separate renal arteries two on the right side (36245), one on the left side (36245).
Diagnostic angiography was performed of the renal arteries. All catheterization work is
bundled into codes 36251‐36254 therefore no catheterization codes are assigned either non‐
selective or selective through the same site of access. Furthermore, these codes are only
assigned one time per side regardless of how many accessory renals are catheterized and
imaged.
The physician placed a stent across the right renal artery occlusion (37236). Note that
angioplasty is bundled with stent placement when performed in the same vessel.
Final CPT® Codes: 36252, 37236
Note: The report does not clearly document superselective catheterization for diagnostic
imaging. The physician would need to be queried on the catheterizations performed.
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Page 229
ST‐3
Clinical History: Recurrent renal artery stenosis.
Procedure: After explaining the risks and benefits of the procedure to the patient, informed
consent was obtained. The patient's right groin was prepped and draped in the usual sterile
fashion and local anesthesia was obtained with 1% Lidocaine solution. A 19 gauge single‐
wall needle was used to puncture the right common femoral artery through which a 0.035
Bentson was passed under fluoroscopic guidance. After dilating the tract, a 4 French Contra
catheter was situated in the suprarenal abdominal aorta. After performing an abdominal
aortogram the catheter was used to advance a TADII wire across the previously placed right
renal artery stent. The catheter was removed and a 7 French guiding catheter —advanced
into the ostium of the renal artery.
A selective right renal arteriogram was performed demonstrating a 70% recurrent ostial
stenosis. 5000 units of heparin were administered. The TADII wire was exchanged for a
0.014 wire which was advanced across the lesion. Under fluoroscopic guidance, a 5 mm x 15
mm Palmaz Blue stent deployed across the ostial stenosis. The follow‐up arteriogram
demonstrates mild residual stenosis with a 20 mmHg gradient. Subsequently, a 6 mm x 2
cm balloon was used to post‐dilate the renal stent. The follow‐up arteriogram shows no
residual stenosis and a 2 mmHg gradient. The guiding catheter was withdrawn and a C1
catheter used to select the left renal artery using an angle tip glide wire. The catheter was
advanced and a TADII wire inserted. The guiding sheath was advanced into the ostium of
the left renal artery and a left renal arteriogram was performed showing a 75% stenosis
within the stent. A 5 mm x 2 cm balloon was used to dilate the stent. The follow‐up
arteriogram shows a 20% residual stenosis with a 15 mmHg gradient. Subsequently, the
stenosis was dilated with a 6 mm x 2 cm balloon. The follow‐up arteriogram shows no
residual stenosis and there is a 6 mmHg residual gradient. Following the procedure the
catheter was removed and hemostasis obtained the StarClose device. There was no bleeding
or hematoma. The patient tolerated the procedure well and left the department in stable
condition.
Findings: The abdominal aorta is diffusely atherosclerotic. Single renal arteries are present
bilaterally. The patient is status post bilateral renal artery stents. A recurrent right renal
artery ostial stenosis is present resulting in a 70% narrowing. Within the previously placed
left renal artery stent is a 75% stenosis.
Impression: 70% recurrent right renal artery stenosis treated with a 5 mm x 15 mm stent
post dilated with a 6 mm balloon. 75% recurrent left renal artery stenosis treated with a 5
mm and 6 mm x 2 cm balloon.
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Page 230
ST‐3 Codes & Explanation
Access was gained at the right common femoral artery (36140) and the catheter was
advanced into the abdominal aorta (36200) for an abdominal aortogram (75625). The
catheter was then advanced into the right renal artery for selective imaging and eventually
the left renal artery (36252). Because diagnostic angiography was performed of the renal
arteries, all catheterization work is bundled into codes 36251‐36254 therefore no
catheterization codes are assigned either non‐selective or selective through the same site of
access. The abdominal aortogram (75625) is also bundled into codes 36251‐36254 therefore it
is not reported.
The physician placed a stent across the right renal artery occlusion (37236). Note that
angioplasty is bundled with stent placement when performed in the same vessel. Next, the
physician performed an angioplasty of the left renal artery (37246). Modifier ‐59 is needed on
the angioplasty codes to denote that the angioplasty was performed on a separate vessel from
the stent placement.
Final CPT® Codes: 36252, 37236, 37246‐59
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Page 231
ST‐4
History: Hypertensive, abnormal ultrasound, renal artery testing.
Procedure: The examination is begun with ultrasound evaluation of the common femoral
arteries. Both are seen to be atherosclerotic with heavy plaque deposition. The left is chosen
for access. A 6‐French sheath is placed. 5‐French flush catheter is positioned in the
suprarenal abdominal aorta. Injection and filming shows severe aortoiliac atherosclerosis
with very irregular plaque throughout the aorta. Moderate stenosis is present in the
proximal left renal artery and severe stenosis of the proximal right renal artery.
A 6 mm outer diameter stent of 1.8 cm in length is placed across the proximal left renal
artery stenosis. Completion injection shows good technical result.
A 6 mm outer diameter stent of 1.8 cm in length is also placed across the right renal artery
stent, which is more resistant to complete expansion but a good lumen is achieved post
stenting with flush aortogram.
There is severe right common iliac artery stenosis incidentally noted during injections. The
superior mesenteric artery and celiac arteries are patent. 3000 units of heparin is
administered during the procedure.
Following the procedure automated clotting time is obtained and the sheath removed with
hemostasis obtained with compression.
Impression:
1. Bilateral proximal main renal artery stenosis as discussed above with technically
successful angioplasty and stent placement.
2. Generalized aortoiliac atherosclerosis with moderately severe narrowing of the
right common iliac artery and thick plaque deposition throughout the aorta and iliac
systems and common femoral arteries bilaterally.
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Page 232
ST‐4 Codes & Explanation
Access was gained at the left common femoral artery (36140) and the catheter was advanced
into the abdominal aorta (36200) for an abdominal aortogram with runoff (75630). Modifier
‐59 is appended to 75630 to indicate this is an initial diagnostic angiogram or that criteria
have been met to report a repeat diagnostic study.
The physician advanced the catheter into the left renal artery for placement of a stent (36245,
37236). Next the physician repeated the same procedure in the right renal artery (36245‐59,
37237) Note angioplasty is bundled with stent placement when performed in the same vessel.
Since the renal imaging was accomplished via a non‐selective imaging study of the aorta,
codes 36251‐36254 do not apply, therefore the catheterization codes for the renal arteries are
reported separately.
Final CPT® Codes: 36245, 36245‐59, 75630‐59, 37236, 37237
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Page 233
ST‐5
INDICATION: Patient with hypertension and acute abdominal pain. CT demonstrating high‐
grade stenoses of the celiac artery and superior mesenteric artery with likely occlusion of
the inferior mesenteric artery.
PROCEDURE PERFORMED:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Catheterization of the superior mesenteric artery.
Superior mesenteric artery arteriogram in lateral projection.
Primary stenting of superior mesenteric artery.
Additional views of the superior mesenteric artery origin.
Selective catheterization of the celiac artery.
Celiac artery arteriogram in the lateral projection.
Balloon angioplasty of celiac artery origin.
Repeat celiac artery angiogram in lateral projection.
Stenting of celiac artery origin.
Repeat celiac artery arteriogram in the lateral projection.
PROCEDURE:
The patient's right groin was prepped and draped in the usual sterile fashion and local
anesthesia was obtained with 1% Lidocaine solution. A 19 gauge single‐wall needle was
used to puncture the right common femoral artery. The sheath was exchanged over a Rosen
wire for a 6‐French Ansel 1 catheter. A CT catheter was used to cannulate the superior
mesenteric artery origin. A lateral arteriogram was performed, demonstrating high‐grade
stenosis of the proximal superior mesenteric artery. The stenosis was crossed and a Rosen
wire was placed. Following, a 7‐26 mm stent was deployed across the stenosis. The
proximal aspect of the stent was flared to 9 mm. Repeat injection of contrast through the
sheath demonstrated fast forward flow with resolution of the previously seen stenosis.
Next, the celiac artery was selected using a glidewire and a C2 catheter. A Rosen wire was
then inserted. Injection of contrast through the sheath at the celiac artery origin
demonstrated a focal 60% stenosis of the origin with post stenotic dilatation. Balloon
angioplasty was performed across the stenosis with 5‐2 balloon. Repeat angiogram
demonstrated no significant change in the appearance of the stenosis. Following, a 0.018
wire was then placed across the stenosis and a 6‐24 stent was then deployed across the
area of narrowing. Repeat injection of contrast demonstrated an excellent result with fast
forward flow through the celiac artery proximally.
Total fluoroscopy time was 14.0 minutes. The patient received 2000 units heparin.
CONCLUSION: High‐grade stenosis of the superior mesenteric artery which underwent
successful stenting, as above, with fast forward flow and resolution of stenosis. High‐grade
stenosis of the origin of the celiac artery which failed angioplasty treatment and underwent
successful stenting, as above.
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Page 234
ST‐5 Codes & Explanation
Access was gained at the right common femoral artery (36140) and the catheter was
advanced into the superior mesenteric artery (36245) for imaging (75726). Modifier ‐59 is
appended to 75726 to indicate this is an initial diagnostic angiogram or that criteria have
been met to report a repeat diagnostic study. Code 36140 the non‐selective catheterization for
the initial access us bundled into selective code 36245. The physician then placed a stent in the
superior mesenteric artery (37236).
Next the catheter was advanced into the celiac (36245) for imaging (75726). Modifier ‐59 is
appended to 75726 to indicate this is an initial diagnostic angiogram or that criteria have
been met to report a repeat diagnostic study. The physician then performed an angioplasty
(37246) followed by placement of a stent in the celiac artery (37237). Note angioplasty is
bundled with stent placement when performed in the same vessel. Code 37236 describes an
initial stent placement and code 37237 describes each additional stent placement.
Final CPT® Codes: 36245, 36245‐59, 37236, 37237, 75726‐59, 75726‐59
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Page 235
ST‐6
Pre‐operative Diagnosis: A 2.7 mm left popliteal artery aneurysm with thrombus.
Post‐operative Diagnosis: A 2.7 mm left popliteal artery aneurysm with thrombus.
PROCEDURES: Left superficial femoral artery cut down. Left lower extremity angiogram.
Stenting of left popliteal artery aneurysm from the distal popliteal artery to the distal SFA
using 9 mm x 10 cm Viabahn distally and a 10 x 15 cm Viabahn proximally. Completion
angiogram. Primary closure of superficial femoral artery.
INDICATIONS: This is a 69‐year‐old male with a history of DVT, obesity, status post gastric
sleeve, who also has a history of polio, who had an incidental finding of a left popliteal
artery aneurysm that was over 2.5 cm with thrombus.
DESCRIPTION OF PROCEDURE: Informed consent was obtained prior to the procedure
after risks and benefits were explained to the patient. The patient was brought into the
operating room and given anesthesia and endotracheally intubated. The left groin was
shaved and then the left leg was prepped with chlorhexidine circumferentially and then
draped circumferentially in sterile fashion. The patient was given preoperative antibiotics
and a time‐out was performed.
We made an incision longitudinally below the groin crease right directly onto the
possession of the SFA with a #10 blade. We came through subcutaneous tissues with Bovie
cautery down to the level of the sartorial fascia. We then mobilized the sartorius muscle
medially and identified the SFA, which we dissected out sharply with Metzenbaum scissors.
We got vessel loops around the proximal portion of the SFA and the SFA was very soft.
Using a micropuncture needle, we accessed the SFA in antegrade fashion and passed a
micropuncture wire down into the distal SFA. This appeared to be in appropriate
placement based on fluoroscopy. We then exchanged the micropuncture needle for
micropuncture sheath over the wire using Seldinger technique. We then placed the Benton
wire down into the distal SFA and exchanged the micropuncture sheath for a 5‐French short
Brite tip sheath. At this point, we did our left lower extremity runoff. (please see
angiographic findings), and then using a 0.035 angled Glidewire and a 0.035 Quick‐Cross
catheter, we navigated our wire into the posterior tibial artery, and then over the Quick‐
Cross exchanged the Glidewire for an 0.035 Magic Torque wire. Over this wire, we then
exchanged our short 5‐French sheath for a short 11‐French Brite tip sheath. We then
performed our runoff again identifying our distal and proximal landing zones and our site of
the aneurysm. The patient was heparinized. We then deployed a 9 mm x 10 cm Viabahn
stent under roadmap in the distal popliteal artery, proximal to the anterior tibial artery
takeoff. We then deployed under roadmap again a 10 x 15 cm Viabahn within the previous
Viabahn overlapping approximately 5 cm. We then ballooned the distal Viabahn with an 8 x
20 mm Mustang balloon over the wire and then we ballooned our Viabahn overlap in our
proximal Viabahn with a 9 x 80 mm Mustang balloon. At this point, we performed a
completion angiogram, which showed that we had same runoff as prior to our stent
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Page 236
placement and that the aneurysm was no longer filling. At this point, we removed our
sheath and clamped the proximal and distal SFA in the area proximal and distal to the
sheath entry site. The patient was heparinized prior to the angioplasty and the clamping.
We then slightly opened up the arteriotomy with the micro Polls scissors transversely and
we closed the arteriotomy using interrupted 6‐0 Prolene sutures. Prior to completing our
arterial closure, we flushed proximally and distally. We then opened up the arteries after we
tied down all the sutures and there was an excellent pulse in the arteries. At this point, we
copiously irrigated. There was good hemostasis, so we did not feel that we needed to
reverse the heparin. We allowed the sartorius to naturally lie back over the artery and then
we closed the subcutaneous tissues in 2 layers, 1 with a running 2‐0 Monocryl and then in a
running 3‐0 Monocryl, and then closed the skin with staples and placed a dressing over the
skin. The patient was awoken from anesthesia, was extubated and transferred to the PACU
in stable condition.
ANGIOGRAPHIC FINDINGS: There is a large over 2.5 cm aneurysm in the popliteal artery
and a smaller aneurysm distal to that. SFA is widely patent as well as popliteal artery with
some evidence of possible arteriomegaly and the posterior tibial artery gives runoff all the
way down to the foot. The peroneal artery also gives runoff down to the calf. The anterior
tibial artery is opened at its origin and then appears to occlude into collaterals. After
placement of the stent, the aneurysm was no longer filling. There is good apposition, there
was no dissection, there was no dissection, no extravasation of contrast and the runoff was
identical prior to stent placement.
ST‐6 Codes & Explanation
Access was gained at the left superficial femoral artery (36140) and imaging was performed of
the left lower extremity (75710). The catheter was then advanced into the popliteal artery
(36245). In this case the popliteal is a first order vessel because access was gained at the
superficial femoral and the catheter was advanced down in the direction of the foot. The non‐
selective catheterization code for the point of access is bundled with code 36245 for the
selective catheterization.
Overlapping stents were placed to treat an aneurysm in the popliteal. Since the clinical
indication was aneurysm and not occlusive disease, code 37236 is assigned over code 37226.
The lower extremity revascularization codes are assigned for occlusive disease and codes
37236‐37237 are assigned for stent placement for indications other than occlusive disease.
Code 37236 is reported one time per vessel, not per stent placed. Overlapping stents were
placed to treat the same vessel.
Modifier ‐59 is appended to 75710 to indicate this is an initial diagnostic angiogram or that
criteria have been met to report a repeat diagnostic study.
Final CPT® Codes: 36245, 75710‐59‐LT, 37236
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Page 237
ST‐7
DESCRIPTION OF EXAM: Left carotid angiogram with angioplasty and stent placement.
INDICATION: This is a 77‐year‐old male who is status post prior bilateral carotid
endarterectomies, the most recent of which was on the left in December 2014. The patient
has since developed a significant greater than 80% origin stenosis of the left internal carotid
artery. The patient admits to mild intermittent visual disturbances, although he does not
describe blindness.
PROCEDURAL STEPS
1.
2.
3.
4.
5.
6.
7.
8.
Percutaneous access of right common femoral artery.
Selective catheterization of the left common carotid artery.
Common carotid arteriogram.
Subselective catheterization of the left internal carotid artery.
Percutaneous transluminal angioplasty of the left internal carotid artery.
Post‐angioplasty left common carotid arteriogram.
Percutaneous transluminal stenting of the left internal carotid artery.
Follow‐up left common carotid arteriogram.
PROCEDURE: After informed consent was obtained, the patient was placed supine on the
angiography table. The right groin is sterilely prepped and draped. Skin and underlying soft
tissues were locally anesthetized with buffered 1% Lidocaine. A small skin nick was then
made. Using a micropuncture needle set and under ultrasound guidance, the right common
femoral artery was percutaneously accessed followed by passage of a 0.018 inch guidewire
centrally. Over this, tracts were serially dilated followed by placement of a 6 French Cook
Shuttle sheath. This was passed to the level of the descending thoracic aorta. The inner
dilator was removed followed by placement of a 6 French JB1 catheter over the wire. This
was then used to engage the origin of the left common carotid artery and a 0.035 inch
guidewire was passed distally into the common carotid artery. The catheter was then
advanced and the guidewire removed. Subsequent injection of the catheter was then carried
out to confirm positioning within the left common carotid artery. Subsequent common
carotid arteriograms were obtained both at the bifurcation and at the left hemispheric
arterial vasculature.
Using a digital roadmap technique, a 0.035 inch STORQ wire was passed into the external
carotid artery. The JB1 catheter and Shuttle sheath were then advanced to the level of the
distal left common carotid artery. The guidewire and JB1 catheter were then removed. Via
the Shuttle sheath, a Cordis filter wire was passed across the ICA stenosis into the distal
internal carotid artery. The filter wire was deployed and the catheter removed. Over the
wire a 4 mm angioplasty balloon catheter was passed and inflated across the origin of the
left internal carotid artery. The balloon catheter was then removed. Subsequently hand
injection of contrast was carried out confirming positioning of the sheath. Over the wire, an
8 x 40 mm Precise stent was passed and deployed across the origin of the internal carotid
artery into the carotid bulb. The deploying mechanism was then removed. Over the wire the
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Page 238
capturing filter catheter was passed. The catheter was then captured under fluoroscopic
guidance and was pulled out of the internal carotid artery and out the sheath. Follow‐up
common carotid arteriogram was obtained in multiple projections showing no significant
residual stenosis of the internal carotid artery. The catheter was then withdrawn and was
exchanged for a short 6 French sheath. The patient was then returned to the floor for
further care where serial ACTs could be drawn until adequate anticoagulation levels would
allow for sheath removal. The patient otherwise tolerated the procedure well with no
immediate complications. Inspection of the filter wire following the procedure revealed no
underlying embolic material.
FINDINGS:
The left common carotid artery is widely patent throughout. The carotid bulb is
unremarkable. The external carotid artery shows minimal disease proximally, but is
without significant stenosis. External carotid arterial branches are unremarkable. The
internal carotid artery shows a fairly concentric 1 cm length short segment origin stenosis
of at least 80% using post NASCET criteria. The distal internal carotid artery is otherwise
patent and smoothly contoured throughout.
Post angioplasty stent placement images of the left internal carotid artery show interval
stenting across the origin of the left internal carotid artery with only minimal residual
stenosis. Brisk flow is demonstrated throughout.
CONCLUSION: Recurrent greater than 80% origin stenosis of the left internal carotid
artery. Status post percutaneous transluminal angioplasty with stenting, without significant
residual stenosis demonstrated.
ST‐7 Codes & Explanation
Access was gained at the right common femoral artery (36140) and the catheter was
advanced into the left common carotid artery for imaging. The findings mention both the
common and carotid and distal internal carotid described by code 36223 which bundles code
36140, however all ipsilateral catheterizations and imaging is bundled with the code for the
stent placement, therefore the only code to assign for this case is 37215.
Final CPT® Codes: 37215
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