Rita Bartholomew
Guru
How would this be coded? 75625, 75710, 37221 and 37224-74??
PREOPERATIVE DIAGNOSIS: Atherosclerosis with tissue loss, right foot.
POSTOPERATIVE DIAGNOSIS: Atherosclerosis with tissue loss, right foot.
NAME OF PROCEDURE:
1. Angiogram of the abdominal aorta and right lower extremity.
2. Stent placement, right external iliac artery.
3. Unsuccessful attempt at crossing the right superficial femoral artery, unsuccessful attempt at accessing the right superficial femoral artery.
SURGEON: Xxxx X. Xxxxx, MD
ANESTHESIA: Local with moderate sedation.
EBL: Minimal.
COMPLICATIONS: None.
ACCESS: 6-French sheath, left common femoral artery, retrograde.
RADIOLOGIC FINDINGS:
1. The abdominal aorta was patent with solitary renal arteries bilaterally. On the left side, there was approximately 50% calcific stenosis near the origin of the common iliac artery. On the right side, a 40% right common iliac artery stenosis near the origin was noted with severe calcification.
2. Several marble-like radiolucencies were noted within the distal-most left common iliac artery and left external iliac artery which were not hemodynamically significant. On the right side, a similar calcified lesion was noted in the external iliac artery proximally and in the internal iliac artery proximally. Right and left hypogastric arteries were patent.
3. The right external iliac artery had several areas of significant calcifications to which were significantly occlusive. The left common femoral artery was patent.
4. A right hip prosthesis made imaging of the right common femoral artery more difficult than usual.
The right proximal common femoral artery was crossed successfully, but I could not cross into the proximal right superficial femoral artery which was chronically totally occluded near its origin. The right profunda femoris artery was also chronically totally occluded near its origin. Numerous collaterals radiated from the external iliac artery and common femoral artery proximally and entered the more distal profunda femoris artery and the more distal superficial femoral artery. These reconstituted the superficial femoral artery. The superficial femoral artery was then patent for 10 cm in the proximal thigh and then became chronically totally occluded. The distal superficial femoral artery then reconstituted and the popliteal artery was noted to be patent. Just above the knee, the popliteal artery had a 60-70% lesion. A right knee prosthesis also diminished imaging of the right popliteal artery behind the knee. After failing to successfully cross the right proximal-most SFA lesion from above, I then attempted to access the right superficial femoral artery and the right popliteal artery and these were unsuccessful.
At this point, I decided to place a stent within the right external iliac artery and a 9 x 40 balloon was used to post-dilate a 10-mm x 60-mm LifeStent in the external iliac position. Completion angiogram showed significant improvement in flow in the right external iliac artery.
I accepted this result.
CLINICAL HISTORY: This pleasant 65-year-old woman has atherosclerosis with ischemic rest pain and tissue loss of the right foot. She comes for arteriography with the intention to treat. ABIs were noted to be very diminished bilaterally.
PROCEDURE REPORT: The patient was taken to the Cardiac Catheterization Laboratory where she was placed on the table in the dorsal recumbent position. After excellent induction with moderate sedation, the skin of the groin area was prepared and draped in a standard sterile fashion. I then called a time-out for correct patient and procedural identification per Xxxxx Hospital protocol. Under local anesthesia and using Seldinger technique and using color flow Duplex ultrasound for guidance, I accessed the left common femoral artery in the retrograde direction. A 5-French sheath was inserted and aspirated and flushed easily. Through the sheath, I advanced an Omniflush catheter into the abdominal aorta. The Omniflush catheter was advanced into the L1-L2 vertebral body position and the guide wire was removed and bubbles were removed from the catheter; 3000 units of unfractionated heparin then administered IV. I then performed an angiogram of the abdominal aorta through the Omniflush catheter. The catheter was then pulled down to the aortic bifurcation where oblique images of the iliofemoral and pelvic runoff were obtained.
Next, I selectively catheterized the right common femoral artery from the left side. This did prove to be quite difficult due to the patient's right hip prosthesis. Additional images of the right lower extremity were obtained. I could not obtain meaningful images below the knee, although it appeared that the patient had 1-vessel run-off via the anterior tibial artery at the level of the distal ankle. Severe calcification was noted in the right lower extremity.
Next, I exchanged the 5-French sheath over a stiff guide wire for a 6-French Ansel-II sheath. The Ansel-II sheath was advanced into the distal external iliac artery. Using a combination of catheters and wires, I was unable to cross the right superficial femoral artery lesion. A 0.018-inch treasure 12 wire, a 0.018-inch Astato wire, a standard stiff and straight glide wire measuring 0.035 were all used in combination with supporting catheters. I then attempted to access the right superficial femoral artery distally and work backwards through the lesion and this was also unsuccessful as severe calcifications precluded accessing the right superficial femoral artery.
At this point, I decided to treat the right external iliac artery only and determined that the patient would likely need an open surgical approach to her right common femoral artery lesion and might need either bypass, angioplasty or stent placement in the right superficial femoral artery.
I then selected a LifeStent measuring 10 mm x 60 mm and this was deployed across the right external iliac artery lesions. These were then post-dilated with a 9-mm x 60 balloon. A completion arteriogram was performed. This demonstrated significant improvement in the right external iliac artery caliber and flow. I tried, once again, to cross the right superficial femoral artery after this and this was also, again, unsuccessful. I terminated the procedure. The sheath was removed. No closure device was used due to left common femoral artery disease. Direct pressure was applied until meticulous hemostasis was achieved.
PREOPERATIVE DIAGNOSIS: Atherosclerosis with tissue loss, right foot.
POSTOPERATIVE DIAGNOSIS: Atherosclerosis with tissue loss, right foot.
NAME OF PROCEDURE:
1. Angiogram of the abdominal aorta and right lower extremity.
2. Stent placement, right external iliac artery.
3. Unsuccessful attempt at crossing the right superficial femoral artery, unsuccessful attempt at accessing the right superficial femoral artery.
SURGEON: Xxxx X. Xxxxx, MD
ANESTHESIA: Local with moderate sedation.
EBL: Minimal.
COMPLICATIONS: None.
ACCESS: 6-French sheath, left common femoral artery, retrograde.
RADIOLOGIC FINDINGS:
1. The abdominal aorta was patent with solitary renal arteries bilaterally. On the left side, there was approximately 50% calcific stenosis near the origin of the common iliac artery. On the right side, a 40% right common iliac artery stenosis near the origin was noted with severe calcification.
2. Several marble-like radiolucencies were noted within the distal-most left common iliac artery and left external iliac artery which were not hemodynamically significant. On the right side, a similar calcified lesion was noted in the external iliac artery proximally and in the internal iliac artery proximally. Right and left hypogastric arteries were patent.
3. The right external iliac artery had several areas of significant calcifications to which were significantly occlusive. The left common femoral artery was patent.
4. A right hip prosthesis made imaging of the right common femoral artery more difficult than usual.
The right proximal common femoral artery was crossed successfully, but I could not cross into the proximal right superficial femoral artery which was chronically totally occluded near its origin. The right profunda femoris artery was also chronically totally occluded near its origin. Numerous collaterals radiated from the external iliac artery and common femoral artery proximally and entered the more distal profunda femoris artery and the more distal superficial femoral artery. These reconstituted the superficial femoral artery. The superficial femoral artery was then patent for 10 cm in the proximal thigh and then became chronically totally occluded. The distal superficial femoral artery then reconstituted and the popliteal artery was noted to be patent. Just above the knee, the popliteal artery had a 60-70% lesion. A right knee prosthesis also diminished imaging of the right popliteal artery behind the knee. After failing to successfully cross the right proximal-most SFA lesion from above, I then attempted to access the right superficial femoral artery and the right popliteal artery and these were unsuccessful.
At this point, I decided to place a stent within the right external iliac artery and a 9 x 40 balloon was used to post-dilate a 10-mm x 60-mm LifeStent in the external iliac position. Completion angiogram showed significant improvement in flow in the right external iliac artery.
I accepted this result.
CLINICAL HISTORY: This pleasant 65-year-old woman has atherosclerosis with ischemic rest pain and tissue loss of the right foot. She comes for arteriography with the intention to treat. ABIs were noted to be very diminished bilaterally.
PROCEDURE REPORT: The patient was taken to the Cardiac Catheterization Laboratory where she was placed on the table in the dorsal recumbent position. After excellent induction with moderate sedation, the skin of the groin area was prepared and draped in a standard sterile fashion. I then called a time-out for correct patient and procedural identification per Xxxxx Hospital protocol. Under local anesthesia and using Seldinger technique and using color flow Duplex ultrasound for guidance, I accessed the left common femoral artery in the retrograde direction. A 5-French sheath was inserted and aspirated and flushed easily. Through the sheath, I advanced an Omniflush catheter into the abdominal aorta. The Omniflush catheter was advanced into the L1-L2 vertebral body position and the guide wire was removed and bubbles were removed from the catheter; 3000 units of unfractionated heparin then administered IV. I then performed an angiogram of the abdominal aorta through the Omniflush catheter. The catheter was then pulled down to the aortic bifurcation where oblique images of the iliofemoral and pelvic runoff were obtained.
Next, I selectively catheterized the right common femoral artery from the left side. This did prove to be quite difficult due to the patient's right hip prosthesis. Additional images of the right lower extremity were obtained. I could not obtain meaningful images below the knee, although it appeared that the patient had 1-vessel run-off via the anterior tibial artery at the level of the distal ankle. Severe calcification was noted in the right lower extremity.
Next, I exchanged the 5-French sheath over a stiff guide wire for a 6-French Ansel-II sheath. The Ansel-II sheath was advanced into the distal external iliac artery. Using a combination of catheters and wires, I was unable to cross the right superficial femoral artery lesion. A 0.018-inch treasure 12 wire, a 0.018-inch Astato wire, a standard stiff and straight glide wire measuring 0.035 were all used in combination with supporting catheters. I then attempted to access the right superficial femoral artery distally and work backwards through the lesion and this was also unsuccessful as severe calcifications precluded accessing the right superficial femoral artery.
At this point, I decided to treat the right external iliac artery only and determined that the patient would likely need an open surgical approach to her right common femoral artery lesion and might need either bypass, angioplasty or stent placement in the right superficial femoral artery.
I then selected a LifeStent measuring 10 mm x 60 mm and this was deployed across the right external iliac artery lesions. These were then post-dilated with a 9-mm x 60 balloon. A completion arteriogram was performed. This demonstrated significant improvement in the right external iliac artery caliber and flow. I tried, once again, to cross the right superficial femoral artery after this and this was also, again, unsuccessful. I terminated the procedure. The sheath was removed. No closure device was used due to left common femoral artery disease. Direct pressure was applied until meticulous hemostasis was achieved.