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INDICATION: Intermittent claudication, peripheral artery disease.
PROCEDURE PERFORMED: Sequential self-expanding stent placement to the left superficial femoral artery with access of the right common femoral artery and the catheter placement to the third order common femoral artery on the left side and sequential stent placement.
HISTORY OF PRESENT ILLNESS: history of PAD, hypertension, dyslipidemia and diabetes with intermittent claudication. He was discovered on noninvasive imaging to have bilateral significant stenosis and symptom-limiting claudication. He underwent angiography that revealed sequential stenosis seen in the mid and distal left SFA system as well as in the right SFA system. He had recently undergone percutaneous intervention of the right system successfully and presents for a staged procedure of the left.
PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. Bilateral groins were prepped in sterile fashion. An attempted antegrade approach on the left common femoral artery was extremely challenging due to the patient's pannus and body habitus. Despite cannulation of the common femoral artery on the left side, due to tissue tension and pressure from his pannus, we were unable to advance a sheath. The procedure site was abandoned and access was the right femoral artery. Again, significant difficulty encountered due to the patient's extensive pannus. Access was then achieved. A wire was advanced across the bifurcation with an IMA catheter. Next, a 90 cm Destination Glidesheath was then advanced across the bifurcation with selective injection revealed we were in the venous system. The procedure site was then abandoned and a 7-French sheath was then sewn in place. Next, a right common femoral artery was accessed using modified Seldinger technique of which a 6-French sheath was then placed. Over an Amplatz stiff wire a long sheath was then placed. IMA catheter was then used to cross over the bifurcation and over a long wire the 90 cm Destination sheath was then placed in the proximal to the common femoral artery. This allowed a Terumo Glidewire to navigate the sequential stenoses seen in the proximal and midvessel, and the wire was placed distal to the popliteal. Next, Angiomax was used for anticoagulation and an over the wire balloon was then placed to the distal lesion. This was measured with glow tape and through this over the wire balloon, a starter wire was then placed distally for safer distal protection. The balloon was then used to predilate sequentially of the SFA. Next, a 6.0 x 60 Armada self-expanding stent was deployed distally. A 6.0 x 40 was then placed in sequential fashion. A Bard 6.0 x 80 was then placed more proximally. There was residual stenosis distally and a 6.0 x 40 Bard stent was then placed distally; however, this jumped forward, leaving a mild gap segment. The entire stented segments were then postdilated with a 6.0 balloon revealing TIMI-III flow and 0% residual stenosis. The sheaths were sewn in. The patient will be monitored overnight. There was moderate blood loss noted. We will monitor the groin site closely and we thank you for the opportunity to participate in the care of this fine gentleman.
Visit Code:
Procedure Codes:
36140 ESTABLISH ACCESS TO ARTERY.
75710 ARTERY X-RAYS, ARM/LEG. Modifiers: 26, 59
36247 PLACE CATHETER IN ARTERY.
37226 FEM/POPL REVASC W/STENT.
99220 Observation Care Intitial - High Complexity. Modifiers: 25
I really do not understand these and can not get a picture for it. Are the modifiers correct also Thanks Nancy
PROCEDURE PERFORMED: Sequential self-expanding stent placement to the left superficial femoral artery with access of the right common femoral artery and the catheter placement to the third order common femoral artery on the left side and sequential stent placement.
HISTORY OF PRESENT ILLNESS: history of PAD, hypertension, dyslipidemia and diabetes with intermittent claudication. He was discovered on noninvasive imaging to have bilateral significant stenosis and symptom-limiting claudication. He underwent angiography that revealed sequential stenosis seen in the mid and distal left SFA system as well as in the right SFA system. He had recently undergone percutaneous intervention of the right system successfully and presents for a staged procedure of the left.
PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. Bilateral groins were prepped in sterile fashion. An attempted antegrade approach on the left common femoral artery was extremely challenging due to the patient's pannus and body habitus. Despite cannulation of the common femoral artery on the left side, due to tissue tension and pressure from his pannus, we were unable to advance a sheath. The procedure site was abandoned and access was the right femoral artery. Again, significant difficulty encountered due to the patient's extensive pannus. Access was then achieved. A wire was advanced across the bifurcation with an IMA catheter. Next, a 90 cm Destination Glidesheath was then advanced across the bifurcation with selective injection revealed we were in the venous system. The procedure site was then abandoned and a 7-French sheath was then sewn in place. Next, a right common femoral artery was accessed using modified Seldinger technique of which a 6-French sheath was then placed. Over an Amplatz stiff wire a long sheath was then placed. IMA catheter was then used to cross over the bifurcation and over a long wire the 90 cm Destination sheath was then placed in the proximal to the common femoral artery. This allowed a Terumo Glidewire to navigate the sequential stenoses seen in the proximal and midvessel, and the wire was placed distal to the popliteal. Next, Angiomax was used for anticoagulation and an over the wire balloon was then placed to the distal lesion. This was measured with glow tape and through this over the wire balloon, a starter wire was then placed distally for safer distal protection. The balloon was then used to predilate sequentially of the SFA. Next, a 6.0 x 60 Armada self-expanding stent was deployed distally. A 6.0 x 40 was then placed in sequential fashion. A Bard 6.0 x 80 was then placed more proximally. There was residual stenosis distally and a 6.0 x 40 Bard stent was then placed distally; however, this jumped forward, leaving a mild gap segment. The entire stented segments were then postdilated with a 6.0 balloon revealing TIMI-III flow and 0% residual stenosis. The sheaths were sewn in. The patient will be monitored overnight. There was moderate blood loss noted. We will monitor the groin site closely and we thank you for the opportunity to participate in the care of this fine gentleman.
Visit Code:
Procedure Codes:
36140 ESTABLISH ACCESS TO ARTERY.
75710 ARTERY X-RAYS, ARM/LEG. Modifiers: 26, 59
36247 PLACE CATHETER IN ARTERY.
37226 FEM/POPL REVASC W/STENT.
99220 Observation Care Intitial - High Complexity. Modifiers: 25
I really do not understand these and can not get a picture for it. Are the modifiers correct also Thanks Nancy