Rita Bartholomew
Guru
Need help with appropriateness of 75774 bilaterally in this situation. Here are the codes I have so far: 75625, 75716, 37221 and 37221-59.
PREOPERATIVE DIAGNOSIS: Atherosclerosis and ischemic [*]___________ pain, right lower extremity.
POSTOPERATIVE DIAGNOSIS: Same.
NAME OF PROCEDURE:
1. Angiogram of the abdominal aorta with bilateral lower extremity runoff.
2. Covered stent placement, right common iliac artery.
3. Stent placement left common iliac artery.
SURGEON: Xxxxl X. Xxxxx, M.D.
ANESTHESIA: Local with moderate sedation.
EBL: Minimal.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The abdominal aorta was noted to be patent with two renal arteries on the right and two renal arteries on the left. The left nephrogram and left renal arteries were not well visualized due to the position of the catheter tip. On the right side, there did not appear to be a significant stenosis.
Surgical clips were present in the right middle and lower quadrant consistent with prior surgery. The right colon was enlarged and full of stool.
The abdominal aorta was patent with a stump of right common iliac artery noted. The right common iliac artery became totally occluded beyond this 1 cm stump for a length of approximately 5 cm. On the left side, the common iliac artery, although patent, was noted to have a 60% stenosis distally over a length of 1-2 cm. The left hypogastric artery had a 99% occlusive lesion at its origin and gave rise to a very diseased-appearing hypogastric artery. The left external iliac artery was patent. On the right side, distal to the area of occlusion, the distal common iliac artery reconstituted for approximately 1 cm at which point it branched into internal iliac and external iliac arteries. The external iliac artery had a focal stenosis of approximately 70%.
On the left side, there was a very significant common femoral artery plaque. The common femoral artery gave rise to the profunda femoris and superficial femoral arteries. The profunda femoris was somewhat diminutive and the superficial femoral artery had multi-focal areas of stenosis. The above-the-knee popliteal artery had an area of 70% stenosis; the mid popliteal artery had an area of 50-60% stenosis; and the below-the-knee popliteal artery had an area of approximately 40% stenosis. There was a high branching of the anterior tibial artery into common tibial peroneal trunk, which occurred approximately 3 cm below the knee. The common TP trunk was quite long. The anterior tibial artery took a somewhat tortuous course. Common TP trunk branched into posterior tibial and peroneal arteries, both of which were extremely diseased and became totally occluded. The anterior tibial artery was the dominant runoff to the left foot. The posterior tibial artery did appear to be continuous in the distal third of the calf into the foot. Significant motion artifact was present.
Additional images of the lower extremity showed, again, dominant posterior tibial artery runoff and the peroneal artery giving a very significant rise that appeared to feed the posterior tibial artery distally. The posterior tibial artery itself appeared to be totally occluded.
On the right side, the external iliac artery was patent. Common femoral artery and profunda femoris arteries are also noted to be patent, although, the common femoral artery had a very significant 60-70% occlusive plaque on the back wall.
The right superficial femoral artery was extremely diseased and became totally occluded in the proximal thigh. Significant calcification was noted. The distal side of the superficial femoral artery reconstituted as a small-appearing artery. The popliteal artery above the knee was somewhat small with a plaque which was approximately 60% occlusive above the knee. The behind the knee popliteal artery was patent. This gave rise to an anterior tibial artery again high and a very long common TP trunk. The common TP trunk branched into posterior tibial and peroneal arteries of which the posterior tibial artery appeared to be the most dominant of the 3 arteries. Posterior tibial artery was the dominant runoff to the foot, followed quite late by the anterior tibial artery, which appeared to be continuous, both to the ankle mortise and foot itself. The posterior tibial artery did give rise to one of the pedal arch branches, and the dorsal pedal artery was also continuous into the midfoot.
I was able to place a covered stent in the right common iliac artery after pre-dilating with a 4 mm, followed by a 6 mm, angioplasty balloon. All of these balloons popped on the sharp calcium in the right common iliac artery. Once pre-dilatation was performed, I placed an atrium iCAST stent into the distal common iliac artery and deployed it above the level of the bifurcation to the level of the aortic bifurcation. A 7 x 59 mm stent was used. This stent was then post dilated with a 9 mm balloon. Complete effacement of the balloon was noted proximally but not distally, although the artery was significantly more patent afterwards. On the right side of the hypogastric artery, he had significantly more flow, though still quite a diseased artery. After this was performed and I demonstrated that there was no evidence of embolization, I placed a standard 10 mm x 4 cm stent across the left common iliac artery lesion. This was post dilated with a 9 mm balloon with an excellent result. Upon completion, there was now significantly improved flow in both lower extremities. It was noted that the sheath in the left femoral position, which was a 7-French sheath, was nearly catheter-occlusive. Direct pressure was applied to the exit side.
OPERATIVE REPORT: The patient was taken to the cath lab where she was placed on the table in a dorsal recumbent position. After excellent moderate sedation, the skin of the groin area was prepped and draped in the standard sterile fashion. The patient complained of significant right gluteal discomfort.
A pillow was placed underneath the right gluteus area. Under local anesthesia and moderate sedation, I accessed the left common femoral artery in the retrograde direction. Significant atherosclerosis was noted. The artery was noted to be very difficult to puncture due to the severe calcification, so a stiffened micro-access sheath was used in conjunction with an Amplatz wire. I then introduced a 5-French sheath over the Amplatz wire, and through the 5-French sheath, and Omni Flush catheter was advanced to the elbow in L2 vertebral body level where it was fashioned. Bubbles were removed. The patient was then given 3000 units of unfractionated heparin IV.
After this, an AP angiogram of the abdominal aorta was performed. I then put the catheter down to the aortic bifurcation where [*]___________ to the iliofemoral and pelvic runoff were obtained.
I performed a Bolus-Chase angiogram of both lower extremities, although significant motion artifact was noted. I then removed the Omni Flush catheter from the abdominal aorta and attached the power injector to the sheath in the left common femoral position. Additional images of the left lower extremity were then obtained. I then placed an Omni Soft catheter into the abdominal aorta up and over the bifurcation and parked this at the distal aorta bifurcation. Using this catheter first in conjunction with the Miracle Bros. 3-wire, and this was followed by a straight glide wire. I was eventually able to successfully catheterize the right external iliac artery. This required passage of the wire to the right common femoral artery and then passage of a CXI 0.035 inch catheter up and over the aortic bifurcation where it was used to selectively catheterize the right external iliac artery. Injections to the catheter tip demonstrated that I was, indeed, in the external iliac artery, as did back bleeding. Serialography of the right lower extremity was then performed through the sheath in the catheter in the right external iliac artery. I then exchanged the 5-French sheath up and over the aortic bifurcation, over a Rosen wire, for a 7-French sheath. The tip of the 7-French sheath was parked at the aortic bifurcation. I could not seem to get the sheath up and over the aortic bifurcation. I then used a 4 mm x 4 cm angioplasty balloon, and this was used to dilate the lesion in the right common iliac artery. Upon the first inflation to 10 atmospheres, it was noted that the balloon had popped. The balloon was then inflated to 6 atmospheres in the more common iliac artery and then removed.
A completion angiogram now showed a channel in the right common iliac artery area that had been totally occluded.
I then chose a 6 mm angioplasty balloon, and this was used to dilate the common iliac artery, again with popping of the balloon. Next, I selected an Atrium-covered stent, and this was passed up and over the aortic bifurcation. The stent measured 7 mm in diameter by 59 mm in length. The stent was deployed up and over the aortic bifurcation without significant difficulty, and I was able to position the device and then deploy it just above the level of the hypogastric arteries after taking further images. Complete opening of the balloon was noted, and a completion arteriogram showed significant improvement. A 9 mm x 4 cm angioplasty balloon was then selected and used by angioplasty; first the distal aspect of the new bypass graft, and then the proximal aspect. I did not obtain full effacement distally but proximally I did.
I then pulled the sheath back into the left common iliac artery from the right, and took a 10 mm x 4 cm life stent and deployed this across the hourglass deformity in the left common iliac artery. This was then post dilated with a 9 mm x 4 cm balloon. A good result was noted. A completion arteriogram showed no extravasation of dye. The patient, who had been initially given hydralazine and pain medication, was now noted to be normotensive and comfortable. She no longer had any buttock pain or right lower extremity pain. I accepted this result.
Any guidance on the use of 75774 is appreciated. Thanks all.
PREOPERATIVE DIAGNOSIS: Atherosclerosis and ischemic [*]___________ pain, right lower extremity.
POSTOPERATIVE DIAGNOSIS: Same.
NAME OF PROCEDURE:
1. Angiogram of the abdominal aorta with bilateral lower extremity runoff.
2. Covered stent placement, right common iliac artery.
3. Stent placement left common iliac artery.
SURGEON: Xxxxl X. Xxxxx, M.D.
ANESTHESIA: Local with moderate sedation.
EBL: Minimal.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The abdominal aorta was noted to be patent with two renal arteries on the right and two renal arteries on the left. The left nephrogram and left renal arteries were not well visualized due to the position of the catheter tip. On the right side, there did not appear to be a significant stenosis.
Surgical clips were present in the right middle and lower quadrant consistent with prior surgery. The right colon was enlarged and full of stool.
The abdominal aorta was patent with a stump of right common iliac artery noted. The right common iliac artery became totally occluded beyond this 1 cm stump for a length of approximately 5 cm. On the left side, the common iliac artery, although patent, was noted to have a 60% stenosis distally over a length of 1-2 cm. The left hypogastric artery had a 99% occlusive lesion at its origin and gave rise to a very diseased-appearing hypogastric artery. The left external iliac artery was patent. On the right side, distal to the area of occlusion, the distal common iliac artery reconstituted for approximately 1 cm at which point it branched into internal iliac and external iliac arteries. The external iliac artery had a focal stenosis of approximately 70%.
On the left side, there was a very significant common femoral artery plaque. The common femoral artery gave rise to the profunda femoris and superficial femoral arteries. The profunda femoris was somewhat diminutive and the superficial femoral artery had multi-focal areas of stenosis. The above-the-knee popliteal artery had an area of 70% stenosis; the mid popliteal artery had an area of 50-60% stenosis; and the below-the-knee popliteal artery had an area of approximately 40% stenosis. There was a high branching of the anterior tibial artery into common tibial peroneal trunk, which occurred approximately 3 cm below the knee. The common TP trunk was quite long. The anterior tibial artery took a somewhat tortuous course. Common TP trunk branched into posterior tibial and peroneal arteries, both of which were extremely diseased and became totally occluded. The anterior tibial artery was the dominant runoff to the left foot. The posterior tibial artery did appear to be continuous in the distal third of the calf into the foot. Significant motion artifact was present.
Additional images of the lower extremity showed, again, dominant posterior tibial artery runoff and the peroneal artery giving a very significant rise that appeared to feed the posterior tibial artery distally. The posterior tibial artery itself appeared to be totally occluded.
On the right side, the external iliac artery was patent. Common femoral artery and profunda femoris arteries are also noted to be patent, although, the common femoral artery had a very significant 60-70% occlusive plaque on the back wall.
The right superficial femoral artery was extremely diseased and became totally occluded in the proximal thigh. Significant calcification was noted. The distal side of the superficial femoral artery reconstituted as a small-appearing artery. The popliteal artery above the knee was somewhat small with a plaque which was approximately 60% occlusive above the knee. The behind the knee popliteal artery was patent. This gave rise to an anterior tibial artery again high and a very long common TP trunk. The common TP trunk branched into posterior tibial and peroneal arteries of which the posterior tibial artery appeared to be the most dominant of the 3 arteries. Posterior tibial artery was the dominant runoff to the foot, followed quite late by the anterior tibial artery, which appeared to be continuous, both to the ankle mortise and foot itself. The posterior tibial artery did give rise to one of the pedal arch branches, and the dorsal pedal artery was also continuous into the midfoot.
I was able to place a covered stent in the right common iliac artery after pre-dilating with a 4 mm, followed by a 6 mm, angioplasty balloon. All of these balloons popped on the sharp calcium in the right common iliac artery. Once pre-dilatation was performed, I placed an atrium iCAST stent into the distal common iliac artery and deployed it above the level of the bifurcation to the level of the aortic bifurcation. A 7 x 59 mm stent was used. This stent was then post dilated with a 9 mm balloon. Complete effacement of the balloon was noted proximally but not distally, although the artery was significantly more patent afterwards. On the right side of the hypogastric artery, he had significantly more flow, though still quite a diseased artery. After this was performed and I demonstrated that there was no evidence of embolization, I placed a standard 10 mm x 4 cm stent across the left common iliac artery lesion. This was post dilated with a 9 mm balloon with an excellent result. Upon completion, there was now significantly improved flow in both lower extremities. It was noted that the sheath in the left femoral position, which was a 7-French sheath, was nearly catheter-occlusive. Direct pressure was applied to the exit side.
OPERATIVE REPORT: The patient was taken to the cath lab where she was placed on the table in a dorsal recumbent position. After excellent moderate sedation, the skin of the groin area was prepped and draped in the standard sterile fashion. The patient complained of significant right gluteal discomfort.
A pillow was placed underneath the right gluteus area. Under local anesthesia and moderate sedation, I accessed the left common femoral artery in the retrograde direction. Significant atherosclerosis was noted. The artery was noted to be very difficult to puncture due to the severe calcification, so a stiffened micro-access sheath was used in conjunction with an Amplatz wire. I then introduced a 5-French sheath over the Amplatz wire, and through the 5-French sheath, and Omni Flush catheter was advanced to the elbow in L2 vertebral body level where it was fashioned. Bubbles were removed. The patient was then given 3000 units of unfractionated heparin IV.
After this, an AP angiogram of the abdominal aorta was performed. I then put the catheter down to the aortic bifurcation where [*]___________ to the iliofemoral and pelvic runoff were obtained.
I performed a Bolus-Chase angiogram of both lower extremities, although significant motion artifact was noted. I then removed the Omni Flush catheter from the abdominal aorta and attached the power injector to the sheath in the left common femoral position. Additional images of the left lower extremity were then obtained. I then placed an Omni Soft catheter into the abdominal aorta up and over the bifurcation and parked this at the distal aorta bifurcation. Using this catheter first in conjunction with the Miracle Bros. 3-wire, and this was followed by a straight glide wire. I was eventually able to successfully catheterize the right external iliac artery. This required passage of the wire to the right common femoral artery and then passage of a CXI 0.035 inch catheter up and over the aortic bifurcation where it was used to selectively catheterize the right external iliac artery. Injections to the catheter tip demonstrated that I was, indeed, in the external iliac artery, as did back bleeding. Serialography of the right lower extremity was then performed through the sheath in the catheter in the right external iliac artery. I then exchanged the 5-French sheath up and over the aortic bifurcation, over a Rosen wire, for a 7-French sheath. The tip of the 7-French sheath was parked at the aortic bifurcation. I could not seem to get the sheath up and over the aortic bifurcation. I then used a 4 mm x 4 cm angioplasty balloon, and this was used to dilate the lesion in the right common iliac artery. Upon the first inflation to 10 atmospheres, it was noted that the balloon had popped. The balloon was then inflated to 6 atmospheres in the more common iliac artery and then removed.
A completion angiogram now showed a channel in the right common iliac artery area that had been totally occluded.
I then chose a 6 mm angioplasty balloon, and this was used to dilate the common iliac artery, again with popping of the balloon. Next, I selected an Atrium-covered stent, and this was passed up and over the aortic bifurcation. The stent measured 7 mm in diameter by 59 mm in length. The stent was deployed up and over the aortic bifurcation without significant difficulty, and I was able to position the device and then deploy it just above the level of the hypogastric arteries after taking further images. Complete opening of the balloon was noted, and a completion arteriogram showed significant improvement. A 9 mm x 4 cm angioplasty balloon was then selected and used by angioplasty; first the distal aspect of the new bypass graft, and then the proximal aspect. I did not obtain full effacement distally but proximally I did.
I then pulled the sheath back into the left common iliac artery from the right, and took a 10 mm x 4 cm life stent and deployed this across the hourglass deformity in the left common iliac artery. This was then post dilated with a 9 mm x 4 cm balloon. A good result was noted. A completion arteriogram showed no extravasation of dye. The patient, who had been initially given hydralazine and pain medication, was now noted to be normotensive and comfortable. She no longer had any buttock pain or right lower extremity pain. I accepted this result.
Any guidance on the use of 75774 is appreciated. Thanks all.