carelitz
Guest
We have a cardiologist that is new to our practice and would love any insight into whether i am capturing all the charges accurately. Thanks so much for any help!
i came up with:
75716 2659 (bilateral LE angio)
37252 RT (IVUS non coronary)
36247 59 (3rd order cath placement to the right peroneal artery)
37227 RT (atherectomy and stent to SFA)
99152 (moderation sedation)
PROCEDURES:
1. Right lower extremity intravascular ultrasound including right
peroneal artery, tibioperoneal trunk, popliteal, superficial femoral
artery and common femoral artery ultrasound.
2. Right superficial femoral artery atherectomy, angioplasty, and
self-expanding Eluvia stent 6 x 120 mm, 2 stents.
3. Additional right lower extremity angiogram with catheter placement
to the right peroneal artery.
4. Left lower extremity angiogram.
INDICATIONS FOR PROCEDURE: This is a patient with known
significant peripheral vascular disease, she did have previous peripheral
angiogram and atherectomy and angioplasty of the left lower extremity, and
at that time was found to have at least 80 percent stenosis of the right
superficial femoral artery. She also has significant coronary artery
disease and status post percutaneous coronary intervention. With a
significant activity restricting claudication still bilaterally.
TECHNIQUE: Vascular access obtained to the left common femoral artery
with micropuncture kit in modified Seldinger technique, and a 6-French 45
cm sheath was advanced, and with the support of 6-French IM catheter
advanced across the aortic bifurcation, and placed to the right common
femoral artery and used for the rest of right lower extremity
intervention.
The left lower extremity angiogram was performed through this sheath,
which was pulled back the tip of it in the left external iliac artery. At
the end of the procedure, sheath was exchanged to the standard length
7-French sheath.
Moderate sedation provided with IV Versed and fentaNYL.
Local anesthesia with lidocaine 2 percent 15 mL to the left groin.
Anticoagulation with IV heparin throughout the procedure with ACT of 219.
HEMODYNAMICS: Arterial pressure was 140/70 mmHg, at the end of the
procedure was 190/80 mmHg, 10 mg IV hydrALAZINE was given.
RIGHT LOWER EXTREMITY ANGIOGRAM:
1. Right common femoral artery is medium-sized vessel without stenosis.
2. Right deep femoral artery is a medium-sized vessel with 50 percent
midportion stenosis.
3. Right superficial femoral artery is a medium-sized vessel with 80
percent proximal, 80-90 percent mid and 80 percent distal portion
stenosis with areas of positive remodeling in the midportion of the
superficial femoral artery.
4. Right popliteal artery is a medium-sized vessel with 40-50 percent
stenosis.
5. Right anterior tibial artery is a small vessel, which is occluded in
proximal-mid portion.
6. Tibioperoneal trunk is a medium-sized vessel, which is patent.
7. Posterior tibial artery is occluded from proximal portion into the
distal.
8. Peroneal artery is a large vessel, patent and provides collaterals
to distal posterior tibial artery, the pedal portion and dorsalis
pedis artery. So this is single vessel runoff with only right
peroneal artery, patent.
9. Intravascular ultrasound of the right lower extremity. Under
fluoroscopy control, we advanced the 300 cm Phoenix wire to the
distal right peroneal artery, then 0.014 Volcano intravascular
ultrasound catheter was advanced to the mid right peroneal artery,
and pulled back into the right common femoral artery was performed
and images were recorded.
RIGHT LOWER EXTREMITY INTRAVASCULAR ULTRASOUND FINDINGS:
1. The peroneal artery is a 3 mm diameter vessel with mild
nonobstructive plaque.
2. The tibioperoneal trunk was 3.5 mm diameter vessel without
obstructive plaque.
1. Popliteal artery is a 4 mm vessel in distal portion, and 4.5 mm
vessel in the mid proximal portion. There is moderate plaque.
There is not more than 40-50 percent area stenosis/plaque burden,
nonobstructive.
2. Superficial femoral artery is a medium-sized vessel. There is 85
percent stenosis in the distal portion, 85-90 percent stenosis in
the midportion, and 85 percent stenosis in the proximal portion.
The vessel has areas of negative remodeling with a diameter of 3 mm,
and areas of positive remodeling in the area of 6.5 mm, in the
midportion.
3. Common femoral artery is a medium-sized vessel, 7.5 mm in diameter,
mild calcified plaque without obstruction present.
ADDITIONAL RIGHT LOWER EXTREMITY ANGIOGRAM: It was obtained through the
0.018 Quick-Cross catheter, advanced to the right mid peroneal artery with
distal circulation images taken. It showed patent peroneal artery all the
way down to the ankle and developed collaterals to the dorsalis pedis
artery, and posterior tibial artery, there is evidence of microvascular
disease with slow flow.
RIGHT SUPERFICIAL FEMORAL ARTERY PHOENIX ATHERECTOMY, ANGIOPLASTY, AND
STENT: Once images were completed, we performed atherectomy with 2.2
Phoenix deflectable arthrectomy device from proximal into the distal
superficial femoral artery. The 3 passes in different quadrants were
made. Then we performed angioplasty with 4 x 200 mm balloon, inflated up
to 8 atmospheres for 3 minutes with additional 2 minutes at 2 atmospheres,
2 inflations were made. Then we performed additional angioplasty with 5 x
100 mm AngioSculpt balloon inflated up to 6 atmospheres for 2 minutes with
additional minute of 2 atmospheres sequentially 3 times from distal and
into the proximal right SFA. Verapamil 2.5 mg was given intra-arterially
to treat any spasm.
The intermediate angiogram showed good vessel size gain, however, there
was significant dissection in the mid proximal SFA and stenting was
commenced. Considering areas of negative for positive remodeling, and
relatively soft plaque, I used drug-eluting stents to prevent further
restenosis.
We positioned 6 x 120 mm Eluvia stent from distal into the mid SFA, and
overlapped it with another 6 x 120 mm Eluvia stent from middle to the
proximal SFA and then performed post-dilatation with 5 x 60 mm balloon,
inflated from distal to proximal SFA sequentially up to 8 atmospheres for
45 seconds each inflation.
Final angiogram showed excellent procedural result, full stent expansion
and apposition, 0 percent residual stenosis, no residual dissection,
extravasation and excellent brisk flow to the popliteal artery and
peroneal artery.
LEFT LOWER EXTREMITY ANGIOGRAM:
1. Left common femoral artery is a medium-sized vessel without
significant stenosis.
2. Left deep femoral artery is a medium-sized vessel without
significant stenosis.
3. Left superficial femoral artery is a medium-sized vessel with
diffuse restenosis. The average 40-60 percent range. However, with
2 sequential lesions in mid distal SFA of 80 percent stenosis.
4. Left popliteal artery is a medium-sized vessel with less than 50
percent stenosis.
5. Left anterior tibial artery is occluded proximally.
6. Left tibioperoneal trunk is patent with patent peroneal artery with
a medium-sized vessel supplying the foot.
7. Left posterior tibial artery is occluded proximally.
CONCLUSIONS:
1. Peripheral vascular disease with 80-90 percent stenosis of the right
superficial femoral artery and single vessel peroneal artery below
the knee runoff.
2. Successful intravascular ultrasound-guided atherectomy with Phoenix
device, angioplasty, and 6 x 120 mm Eluvia drug-eluting stent x2.
3. Left superficial femoral artery 80 percent restenosis.
i came up with:
75716 2659 (bilateral LE angio)
37252 RT (IVUS non coronary)
36247 59 (3rd order cath placement to the right peroneal artery)
37227 RT (atherectomy and stent to SFA)
99152 (moderation sedation)
PROCEDURES:
1. Right lower extremity intravascular ultrasound including right
peroneal artery, tibioperoneal trunk, popliteal, superficial femoral
artery and common femoral artery ultrasound.
2. Right superficial femoral artery atherectomy, angioplasty, and
self-expanding Eluvia stent 6 x 120 mm, 2 stents.
3. Additional right lower extremity angiogram with catheter placement
to the right peroneal artery.
4. Left lower extremity angiogram.
INDICATIONS FOR PROCEDURE: This is a patient with known
significant peripheral vascular disease, she did have previous peripheral
angiogram and atherectomy and angioplasty of the left lower extremity, and
at that time was found to have at least 80 percent stenosis of the right
superficial femoral artery. She also has significant coronary artery
disease and status post percutaneous coronary intervention. With a
significant activity restricting claudication still bilaterally.
TECHNIQUE: Vascular access obtained to the left common femoral artery
with micropuncture kit in modified Seldinger technique, and a 6-French 45
cm sheath was advanced, and with the support of 6-French IM catheter
advanced across the aortic bifurcation, and placed to the right common
femoral artery and used for the rest of right lower extremity
intervention.
The left lower extremity angiogram was performed through this sheath,
which was pulled back the tip of it in the left external iliac artery. At
the end of the procedure, sheath was exchanged to the standard length
7-French sheath.
Moderate sedation provided with IV Versed and fentaNYL.
Local anesthesia with lidocaine 2 percent 15 mL to the left groin.
Anticoagulation with IV heparin throughout the procedure with ACT of 219.
HEMODYNAMICS: Arterial pressure was 140/70 mmHg, at the end of the
procedure was 190/80 mmHg, 10 mg IV hydrALAZINE was given.
RIGHT LOWER EXTREMITY ANGIOGRAM:
1. Right common femoral artery is medium-sized vessel without stenosis.
2. Right deep femoral artery is a medium-sized vessel with 50 percent
midportion stenosis.
3. Right superficial femoral artery is a medium-sized vessel with 80
percent proximal, 80-90 percent mid and 80 percent distal portion
stenosis with areas of positive remodeling in the midportion of the
superficial femoral artery.
4. Right popliteal artery is a medium-sized vessel with 40-50 percent
stenosis.
5. Right anterior tibial artery is a small vessel, which is occluded in
proximal-mid portion.
6. Tibioperoneal trunk is a medium-sized vessel, which is patent.
7. Posterior tibial artery is occluded from proximal portion into the
distal.
8. Peroneal artery is a large vessel, patent and provides collaterals
to distal posterior tibial artery, the pedal portion and dorsalis
pedis artery. So this is single vessel runoff with only right
peroneal artery, patent.
9. Intravascular ultrasound of the right lower extremity. Under
fluoroscopy control, we advanced the 300 cm Phoenix wire to the
distal right peroneal artery, then 0.014 Volcano intravascular
ultrasound catheter was advanced to the mid right peroneal artery,
and pulled back into the right common femoral artery was performed
and images were recorded.
RIGHT LOWER EXTREMITY INTRAVASCULAR ULTRASOUND FINDINGS:
1. The peroneal artery is a 3 mm diameter vessel with mild
nonobstructive plaque.
2. The tibioperoneal trunk was 3.5 mm diameter vessel without
obstructive plaque.
1. Popliteal artery is a 4 mm vessel in distal portion, and 4.5 mm
vessel in the mid proximal portion. There is moderate plaque.
There is not more than 40-50 percent area stenosis/plaque burden,
nonobstructive.
2. Superficial femoral artery is a medium-sized vessel. There is 85
percent stenosis in the distal portion, 85-90 percent stenosis in
the midportion, and 85 percent stenosis in the proximal portion.
The vessel has areas of negative remodeling with a diameter of 3 mm,
and areas of positive remodeling in the area of 6.5 mm, in the
midportion.
3. Common femoral artery is a medium-sized vessel, 7.5 mm in diameter,
mild calcified plaque without obstruction present.
ADDITIONAL RIGHT LOWER EXTREMITY ANGIOGRAM: It was obtained through the
0.018 Quick-Cross catheter, advanced to the right mid peroneal artery with
distal circulation images taken. It showed patent peroneal artery all the
way down to the ankle and developed collaterals to the dorsalis pedis
artery, and posterior tibial artery, there is evidence of microvascular
disease with slow flow.
RIGHT SUPERFICIAL FEMORAL ARTERY PHOENIX ATHERECTOMY, ANGIOPLASTY, AND
STENT: Once images were completed, we performed atherectomy with 2.2
Phoenix deflectable arthrectomy device from proximal into the distal
superficial femoral artery. The 3 passes in different quadrants were
made. Then we performed angioplasty with 4 x 200 mm balloon, inflated up
to 8 atmospheres for 3 minutes with additional 2 minutes at 2 atmospheres,
2 inflations were made. Then we performed additional angioplasty with 5 x
100 mm AngioSculpt balloon inflated up to 6 atmospheres for 2 minutes with
additional minute of 2 atmospheres sequentially 3 times from distal and
into the proximal right SFA. Verapamil 2.5 mg was given intra-arterially
to treat any spasm.
The intermediate angiogram showed good vessel size gain, however, there
was significant dissection in the mid proximal SFA and stenting was
commenced. Considering areas of negative for positive remodeling, and
relatively soft plaque, I used drug-eluting stents to prevent further
restenosis.
We positioned 6 x 120 mm Eluvia stent from distal into the mid SFA, and
overlapped it with another 6 x 120 mm Eluvia stent from middle to the
proximal SFA and then performed post-dilatation with 5 x 60 mm balloon,
inflated from distal to proximal SFA sequentially up to 8 atmospheres for
45 seconds each inflation.
Final angiogram showed excellent procedural result, full stent expansion
and apposition, 0 percent residual stenosis, no residual dissection,
extravasation and excellent brisk flow to the popliteal artery and
peroneal artery.
LEFT LOWER EXTREMITY ANGIOGRAM:
1. Left common femoral artery is a medium-sized vessel without
significant stenosis.
2. Left deep femoral artery is a medium-sized vessel without
significant stenosis.
3. Left superficial femoral artery is a medium-sized vessel with
diffuse restenosis. The average 40-60 percent range. However, with
2 sequential lesions in mid distal SFA of 80 percent stenosis.
4. Left popliteal artery is a medium-sized vessel with less than 50
percent stenosis.
5. Left anterior tibial artery is occluded proximally.
6. Left tibioperoneal trunk is patent with patent peroneal artery with
a medium-sized vessel supplying the foot.
7. Left posterior tibial artery is occluded proximally.
CONCLUSIONS:
1. Peripheral vascular disease with 80-90 percent stenosis of the right
superficial femoral artery and single vessel peroneal artery below
the knee runoff.
2. Successful intravascular ultrasound-guided atherectomy with Phoenix
device, angioplasty, and 6 x 120 mm Eluvia drug-eluting stent x2.
3. Left superficial femoral artery 80 percent restenosis.
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