Wiki angioplasty/stent


Dayton, Ohio
Best answers
I am hoping for assistance in coding this claim.

"Patient had CT angiogram last week which demonstrated what the physician felt was a high grade left external artery stenosis and diffuse sperficial femoral artery arterial disease. I recommended angioplasty and potentially stent placement."

In the angiography suite, the patient was placed in the supine position. She was sedated. The right femoral region was prepped and draped in the usual sterile manner. One percent lidocaine was used as local anesthetic. This was injected into the skin over the right femoral pulse. I cannulated the right femoral artery with a first pass technique. I passed a 6-French sheath introducer. I exchanged the guidewire for a pigtail catheter. I selected the left common iliac artery with a pigtail catheter and exchanged the pigtail catheter for a multipurpose catheter. I then obtained a runoff with Visipaque of the left common iliac artery to the foot. I then placed a 25-cm and then a 45-cm sheath by the side up and over the bifurcation. I met resistance of the external iliac origin. I felt that this needed to be treated for any further intervention be performed. I passed the lesion with a 0.014 guidewire and over this, a 2-mm balloon that was 4 cm in length. I pre-dilated this with a 2-mm balloon and then exchanged over the guidewire for a 5-mm stent that was 27-mm long. After considerable difficulty, I was able to pass the lesion and angioplasty and stent this area open. After inflating the balloon and removing the stent delivery catheter, I was able to pass my sheath dilator beyond this area down to the external iliac artery. I should mention that throughout this, the patient was received heparin at full strength doses intravenously, by using boluses initially of 5000 units and then dropped to 2500 units until the end of the procedure. I then attempted to cross a long segment of occlusion of the left superficial femoral artery from the right side. I selected the distal left external iliac artery and then the left common iliac artery, and finally the left superficial femoral artery. I was able to pass a guidewire followed quickly by a catheter through the length of the left superficial femoral artery down to the distal aspect of the artery. I was able to pass the guidewire into the popliteal artery which is where I believe it reentered, but I could never confirm this with contrast opacification. I simply did not have the mechanics to pass the catheter to the same depth as the guidewire. This is in spite of attempting multiple manipulations and changing sheaths and changing catheters to glide catheters and selecting a variety of different guide wires. The patient was approaching almost an hour of fluoroscopy time and what I felt to be upper limits of my comfort level of contrast and time on the table so I felt that it was best to conclude the procedure by doing pullback pressures. Using the straight glide catheter in the superficial femoral artery, I began with pullback pressures and obtained them at the distal superficial femoral artery, proximal superficial femoral artery, left common femoral artery, left external iliac artery, left common femoral artery at the proximal location and the distal aorta. I removed the guidewire and catheters. The patient will have pressure held at her right common femoral artery.

Her left external iliac artery had a high-grade stenosis at its origin that would not allow passage of even a 5-French catheter suggesting this was in the range of 90%. I imaging this both in AP view and oblique view and was unable to find greater than a 70% stenosis on imaging, but based on the inability to pass anything beyond this, it was clear this is probably much higher. After predilation, and then percutaneous angioplasty with stent placement with the 5-mm stent, there is complete resolution of this stenosis. There was only a 2 mmHg difference of the mean across this stent once I was done. This is not significant. The distal external iliac artery or femoral artery are minimally diseased with no significant stenosis. Left superficial femoral artery is occluded. This was a surprise given that the patient had what appeared to be an open SFA on her CT angiogram obtained last week. The occlusion length spanned probably 30 cm. The proximal popliteal artery reconstituted probably right at the distal SFA location. Her runoff was through very small vessels down to the foot without another significant stenosis. The pressure in the distal SFA was 64 mmHg (mean). This was 8 mmHg lower than at the proximal SFA which is probably significance. There was no significant difference between the proximal SFA, left common femoral artery mean pressure. There was a slight improvement to 79 mmHg at the external iliac artery distal to the stent. The difference was only 8 mmHg, but there was no significant difference between that and the distal aorta at 80 mmHg mean.

Sheath will be removed. The patient will have a period of usually weeks if not a few months of observation with local wound care. If she fails to improve, I can potentially return with an antegrade approach to the left side to attempt to bridge the superficial femoral artery occlusion. This, of course, is high risk. This is all assuming the patient does well with this procedure.

I am thinking the only thing he can code is the stent placement, but I want to make sure that he cannot code the selective cath and to what degree and the runoff. I appreciate any assistance.