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unsure of this interventional billing; 36245,75630 26 59,75710 26 59,36140,37221,37221 59?
PROCEDURES PERFORMED:
1. Abdominal aortography.
2. Bilateral lower extremity run off.
3. Additional angiographic visualization of the left iliac
artery.
4. Additional arterial access in the contralateral femoral
artery.
5. Angioplasty of the right common iliac artery.
6. Angioplasty of the left common iliac artery.
7. Stent of the right common iliac artery.
8. Stent of the left common iliac artery.
9. Conscious sedation for 2 hours, 15 minutes.
CLINICAL HISTORY:
The patient is a 67-year-old male with severe lower extremity
claudication and a resting ABI of 0.45 in the left lower
extremity, who had been tried on walking and Pletal with
insufficient success. He has had a CT angiogram demonstrating a
short segment occlusion of the left SFA as well as left iliac
disease.
PROCEDURE:
After obtaining informed consent, the patient was transported in
the nonsedated condition to the cardiac catheterization suite. The
patient was prepped and draped in a sterile fashion. Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the right common femoral artery. The patient was given Versed and
Fentanyl in an intermittent fashion starting at 15:00 and the
patient was monitored hemodynamically and respiratory throughout
the procedure which ended at 17:15, a total of two hours and 15
minutes of monitored conscious sedation, a total of 4 mg of
Versed, 250 mcg of Fentanyl, 6000 units of heparin administered.
Percutaneous access was obtained in the right common femoral
artery utilizing the Seldinger technique and a #5 French sheath
was placed. I then advanced a #5 French VCF catheter into the
abdominal aorta. Angiography was performed of the abdominal aorta
to the level of the iliac arteries. Following abdominal
angiography, the VCF catheter was withdrawn to the aortic
bifurcation and we performed a digital subtraction run off of the
lower extremities by injecting 90 cc of contrast over nine
seconds. Following digital subtraction angiography, we obtained
additional angiographic images of the left common iliac artery by
engaging the left common iliac artery selectively with a #5 French
mammary catheter. Multiple views were obtained of the left common
and external iliac arteries prior to the decision to proceed with
intervention. The intervention was described below.
FINDINGS:
Aortic pressure was 136/58, left common iliac artery was 75/53
prior to intervention.
AORTOGRAPHY:
Aortography at the level of the renal arteries demonstrate mild
diffuse atherosclerotic plaquing in the suprarenal aorta. The
celiac artery, superior and inferior mesenteric arteries are
widely patent and their visualized segments are free of
significant obstructive disease. The renal arteries bilaterally
are widely patent with mild ostial atherosclerotic plaquing of
20%. The distal abdominal aorta is aneurysmal. Immediately above
the aortic bifurcation, the internal lumen measures 2.3 cm.
RIGHT LOWER EXTREMITY: The right common iliac artery has ostial
60-70% stenosis. It then becomes somewhat ectatic and has diffuse
atherosclerotic plaquing and calcification up to and including the
right hypogastric artery. That right hypogastric artery has an
ostial 70-80% stenosis but is patent. The right external iliac
artery has diffuse mild atherosclerotic plaquing with a focal
indentation resulting in 40-50% stenosis immediately above the
inguinal ligament. The right common femoral artery has mild
diffuse atherosclerotic plaquing throughout its length. The right
profundofemoris is patent. The right superficial femoral artery
is patent with mild atherosclerotic plaquing in its proximal third
up to 20%. Through the mid SFA, there are sequential 20% and 30%
stenoses. The distal SFA is widely patent. The right popliteal
artery is widely patent. The tibial peroneal trunk is widely
patent. The anterior tibial artery, posterior tibial artery, and
peroneal arteries are patent to the
foot.
LEFT LOWER EXTREMITY: On the left lower extremity, the left
common iliac artery is severely diseased with an 80-90% stenosis
proximally. It is followed by an area of ectasia and then the
left hypogastric artery is not visualized. The left common iliac
artery has moderate atherosclerotic plaquing up to 40-50%. The
left profundofemoris is widely patent and hypertrophied. The left
superficial femoral artery appears to have an ostial 80% stenosis
and then is occluded in the mid segment. There is a short segment
occlusion with reconstitution of the left SFA at Hunter's Canal.
There are very strong collaterals from the profundofemoris to the
distal SFA. The left popliteal artery has mild luminal
irregularities and the proximal third of the inferopopliteal
vessels are visualized but due to the occlusions above, were not
visualized to the level of the foot.
PROCEDURES PERFORMED:
1. Abdominal aortography.
2. Bilateral lower extremity run off.
3. Additional angiographic visualization of the left iliac
artery.
4. Additional arterial access in the contralateral femoral
artery.
5. Angioplasty of the right common iliac artery.
6. Angioplasty of the left common iliac artery.
7. Stent of the right common iliac artery.
8. Stent of the left common iliac artery.
9. Conscious sedation for 2 hours, 15 minutes.
CLINICAL HISTORY:
The patient is a 67-year-old male with severe lower extremity
claudication and a resting ABI of 0.45 in the left lower
extremity, who had been tried on walking and Pletal with
insufficient success. He has had a CT angiogram demonstrating a
short segment occlusion of the left SFA as well as left iliac
disease.
PROCEDURE:
After obtaining informed consent, the patient was transported in
the nonsedated condition to the cardiac catheterization suite. The
patient was prepped and draped in a sterile fashion. Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the right common femoral artery. The patient was given Versed and
Fentanyl in an intermittent fashion starting at 15:00 and the
patient was monitored hemodynamically and respiratory throughout
the procedure which ended at 17:15, a total of two hours and 15
minutes of monitored conscious sedation, a total of 4 mg of
Versed, 250 mcg of Fentanyl, 6000 units of heparin administered.
Percutaneous access was obtained in the right common femoral
artery utilizing the Seldinger technique and a #5 French sheath
was placed. I then advanced a #5 French VCF catheter into the
abdominal aorta. Angiography was performed of the abdominal aorta
to the level of the iliac arteries. Following abdominal
angiography, the VCF catheter was withdrawn to the aortic
bifurcation and we performed a digital subtraction run off of the
lower extremities by injecting 90 cc of contrast over nine
seconds. Following digital subtraction angiography, we obtained
additional angiographic images of the left common iliac artery by
engaging the left common iliac artery selectively with a #5 French
mammary catheter. Multiple views were obtained of the left common
and external iliac arteries prior to the decision to proceed with
intervention. The intervention was described below.
FINDINGS:
Aortic pressure was 136/58, left common iliac artery was 75/53
prior to intervention.
AORTOGRAPHY:
Aortography at the level of the renal arteries demonstrate mild
diffuse atherosclerotic plaquing in the suprarenal aorta. The
celiac artery, superior and inferior mesenteric arteries are
widely patent and their visualized segments are free of
significant obstructive disease. The renal arteries bilaterally
are widely patent with mild ostial atherosclerotic plaquing of
20%. The distal abdominal aorta is aneurysmal. Immediately above
the aortic bifurcation, the internal lumen measures 2.3 cm.
RIGHT LOWER EXTREMITY: The right common iliac artery has ostial
60-70% stenosis. It then becomes somewhat ectatic and has diffuse
atherosclerotic plaquing and calcification up to and including the
right hypogastric artery. That right hypogastric artery has an
ostial 70-80% stenosis but is patent. The right external iliac
artery has diffuse mild atherosclerotic plaquing with a focal
indentation resulting in 40-50% stenosis immediately above the
inguinal ligament. The right common femoral artery has mild
diffuse atherosclerotic plaquing throughout its length. The right
profundofemoris is patent. The right superficial femoral artery
is patent with mild atherosclerotic plaquing in its proximal third
up to 20%. Through the mid SFA, there are sequential 20% and 30%
stenoses. The distal SFA is widely patent. The right popliteal
artery is widely patent. The tibial peroneal trunk is widely
patent. The anterior tibial artery, posterior tibial artery, and
peroneal arteries are patent to the
foot.
LEFT LOWER EXTREMITY: On the left lower extremity, the left
common iliac artery is severely diseased with an 80-90% stenosis
proximally. It is followed by an area of ectasia and then the
left hypogastric artery is not visualized. The left common iliac
artery has moderate atherosclerotic plaquing up to 40-50%. The
left profundofemoris is widely patent and hypertrophied. The left
superficial femoral artery appears to have an ostial 80% stenosis
and then is occluded in the mid segment. There is a short segment
occlusion with reconstitution of the left SFA at Hunter's Canal.
There are very strong collaterals from the profundofemoris to the
distal SFA. The left popliteal artery has mild luminal
irregularities and the proximal third of the inferopopliteal
vessels are visualized but due to the occlusions above, were not
visualized to the level of the foot.