A tricky one

Greater Portland (Maine)
Best answers
This was a tricky one for me. There was a second access with aborted attempt at treatment of the peroneal artery lesion, and there was loss of wire access from the first access necessitating reobtaining wire access with difficulty. These are my codes: 75625, 75716, 37229, 37228-59 (tx after re-wiring--perhaps 36247-59 instead because ballooning was really just a completion of 37229), 36140-59 (aborted attempt from distal PTA access). Also, would 75774 be appropriate where he obtained add'l images of lt calf to better delineate anatomy?

PREOPERATIVE DIAGNOSIS: Atherosclerosis and tissue loss, left lower extremity.

POSTOPERATIVE DIAGNOSIS: Atherosclerosis and tissue loss, left lower extremity.

1. Angiogram of the abdominal aorta with bilateral lower extremity runoff.
2. Rotational atherectomy and balloon angioplasty of the left peroneal artery.

SURGEON: Xxxx X. Xxxxx, MD.

ANESTHESIA: Local with moderate sedation.

EBL: Minimal.

COMPLICATIONS: None (flow-limiting dissection of the peroneal artery treated successfully with balloon angioplasty).

CLINICAL HISTORY: This very pleasant xx-year-old man is status post bilateral 2nd toe amputations. He has had a recent exacerbation of his left foot pain and has ulcerated the left 3rd toe which has a 5 mm x 5 mm nonhealing ulcer at the plantar aspect. Noninvasive arterial studies suggest incompressible arteries and are confusing. There is a possibility of severe arterial insufficiency, so he comes for further imaging to further delineate his anatomy and treat, if possible.

RADIOLOGIC FINDINGS: The abdominal aorta was patent with solitary renal arteries bilaterally. Both common iliac arteries are widely patent. Both internal and external iliac arteries and common femoral arteries were widely patent. On the right side, there was multifocal diffuse superficial femoral artery occlusive disease with several stenoses approaching 60%. There was no evidence of popliteal artery stenosis. Below the level of the knee, there was peroneal artery runoff only and the peroneal artery had several critical-appearing strictures of greater than 60-70% noted. The right profunda femoris artery was patent.

The posterior tibial artery and anterior tibial artery were chronically totally occluded throughout their length.

On the left side, the common femoral artery was patent. The profunda femoris artery was patent. The superficial femoral artery in mirror image fashion to that of the right side had several focal areas of stenosis, but none of these appeared to be more than approximately 50%. The popliteal artery was widely patent. Below the knee, the anterior tibial artery and common TP trunk were chronically totally occluded. The peroneal artery reconstituted for a short length and then had several areas of severe stricture. In the lower 3rd of the leg, the peroneal artery was reconstituted as a reasonably normal-appearing artery. The posterior tibial and anterior tibial arteries were occluded throughout their length.

I was able to successfully cross the peroneal artery with great difficulty. This was then treated with a CSI micro 1.25 crown device. Upon completion, dissection of the peroneal artery was noted. This was treated successfully with balloon angioplasty using a 2.5 x 12-cm angioplasty balloon. A 2nd inflation was required for an area of persistent stenosis, but this resolved after the 2nd angioplasty. Upon completion, there was single-vessel runoff through the peroneal artery throughout its length with no area of total occlusion.

The anterior tibial artery was noted to be patent proximally but then occluded distally. The anterior tibial artery appeared to take off to approximately the mid-knee level.

In the foot, itself, the peroneal artery was the main feeding vessel. A posterior tibial artery came back below the ankle and gave rise to a meaningful distal posterior tibial artery into the foot which gave rise to medial and lateral plantar branches. One of the branches was severely diseased. The dorsal pedal artery reconstituted as a very small artery in the dorsal foot.

OPERATIVE REPORT: The patient was taken to the Cardiac Catheterization Laboratory where he was placed on the table in a dorsal recumbent position. After excellent induction with moderate sedation, the skin of the groin area was prepped and draped in the standard sterile fashion. I then called a time-out for correct patient and procedural identification per Xxxxxxxxx Hospital protocol. Under local anesthesia and using the Micro-Access System, I accessed the right common femoral artery in the retrograde direction using color flow duplex ultrasound guidance with the Terason machine. Next, a 0.018-inch guide wire was advanced easily. This was followed by insertion of a 5-French sheath in the retrograde fashion. Then, 3000 units of unfractionated heparin were administered IV and I aspirated and flushed the sheath. Through the sheath, I advanced an Omniflush catheter to the L1-L2 vertebral body level. The guide wire was removed and bubbles were removed from the catheter. I then performed an AP angiogram of the abdominal aorta. The catheter was then pulled down to the aortic bifurcation where oblique images of the iliofemoral and pelvic runoff were obtained.

A bolus _________ angiogram of the abdominal aorta and bilateral lower extremity runoff was then obtained. The findings were pertinent for severe peripheral arterial occlusive disease below the level of the knee bilaterally with peroneal runoff only bilaterally. On the left side, there was no identifiable runoff of vessel except for the more distal peroneal artery, as there was total occlusion of all 3 vessels.

At this point, I heparinized the patient with 70 mg/kg of unfractionated heparin IV. I then selectively catheterized the left common femoral artery from the right. With this performed, I was able to selectively catheterize the left superficial femoral artery from the right and pass a Rosen wire here. I then removed the 5-French sheath and Omniflush catheter and advanced an Ansel-2 6-French sheath up and over the aortic bifurcation. This was then advanced to the tip in the superficial femoral artery. The sheath was advanced to its hub in the superficial femoral artery.

Next, through the sheath, I advanced a CXI catheter measuring 0.018 inches in diameter along with a Treasure 12 wire. This was used to attempt to selectively catheterize the distal peroneal artery.

I first obtained additional images of the left calf to better delineate the anatomy. This demonstrated a total occlusion in the proximal peroneal artery as well as a significantly tortuous course.

I then used the CXI catheter and the Treasure 12 wire in an attempt to selectively catheterize the distal peroneal artery. Although the tip of the wire appeared to cross most of the total occlusion, it then encountered a significant stenosis distally. With advance of the CXI catheter, the guide wire advanced even further distally but appeared to encounter significant resistance, as though it was in a subintimal plane. I was unable to cross in to what appeared a true lumen and several different images verified that I was, indeed, in a subintimal plane with the tip of the catheter. I used several different wires at this point to attempt to regain access. This was not fruitful. I then used ultrasound and local anesthesia to obtain access of the more distal peroneal artery, but this was unsuccessful. I did obtain access of the more distal posterior tibial artery, but this was not helpful.

I was able to get a tip of a Cope wire into the peroneal artery retrograde but was unable to thread a catheter into the artery.

I then pulled the CXI catheter out of the peroneal artery and obtained a further arteriogram of the left lower extremity to see the result. This demonstrated that I had successfully crossed the area of total occlusion, but a significant subintimal plane was still present. A fine channel was now noted throughout the length of the peroneal artery. I was then able to use a CXI catheter in conjunction with a first day PT Graphix wire and then a Regalia wire. This was used to successfully catheterize the distal peroneal artery. Road mapping was used. With the catheter tip now in the mid to distal peroneal artery, I passed a Viper wire into the peroneal artery. A CSI device was then selected. This was the micro crown device that measured 1.25 mm in diameter. This was used to treat the peroneal artery on low speed. Although the proximal segment treated appeared to spin well, the device appeared to catch on a lesion near here the wire entered the subintimal plane and the device arrested. After several more passes of the device, the device was able to pass through this area, but the device continued to arrest in the area of the lesion. I then pulled out the device and found that the device was frozen to the wire and that I had lost wire access. Reobtaining wire access was quite difficult and required the CXI catheter in conjunction with the PT Graphix wire again.

After reobtaining access, which was successful, I performed a balloon angioplasty throughout the length of the peroneal artery. A very long 2.55-mm balloon was inflated to 2 atmospheres. This did not achieve effacement initially, so the wound was effaced at 3-4 atmospheres. The entire length of peroneal artery was treated. Completion arteriogram showed several areas of residual stenosis of approximately 30%, but the artery was noted to be patent throughout its length. I accepted this result. Mr. Xxxxxx tolerated the procedure well and sponge and needle counts following the case were correct x2. An arteriogram of the right femoral artery demonstrated patency and so an Angio-Seal was deployed bilaterally in both right and left sheaths.

Mr. Xxxxxx tolerated the procedure well and sponge and needle counts following the case were correct x2.

Appreciate any help.