bennieyoung
Guru
This has been denied and I would like to ask that someone look at it and give me their input on the how they would code it.
INDICATION FOR PROCEDURE: Severe symptomatic claudication.
PROCEDURES:
1. Left radial artery access.
2. Abdominal aortogram.
3. Shockwave atherectomy of right common iliac artery.
4. Percutaneous transluminal coronary angioplasty and stenting of right distal external iliac artery with Misago 7.0 x 60 mm stent.
5. Percutaneous transluminal coronary angioplasty and stenting of right common iliac artery using balloon expandable 8.0 x 37 mm balloon expandable stent.
6. Stenting of right common iliac artery with balloon expandable 8.0 x 17 mm balloon expandable stent.
HISTORY: Briefly, this is a 78-year-old female history of severe claudication, known bilateral iliac/external iliac artery disease. The patient was consented for a peripheral vascular angiogram, plus or minus stenting.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to BCH, where the left wrist was prepped in sterile fashion. After Allen test confirmed patency of ulnar artery using local lidocaine, a 6-French sheath placed in the left radial artery. The patient was given 2000 heparin, 200 mcg of nitroglycerin through the sheath.
A pigtail catheter was advanced over an 0.035 wire to the descending aorta. Abdominal aortogram was obtained, which showed patent distal aorta, patent left common iliac artery ostium. The left internal iliac artery was patent. The left external iliac artery was 100% occluded after its initial takeoff. There was reconstitution of the common femoral artery in its mid femoral head via internal iliac collaterals. The right common iliac artery had an ostial 30% to 40% narrowing. Distal to this, there was aneurysmal formation of the iliac artery with diffuse dissection planes throughout the prox mid common iliac artery. The internal iliac artery was patent. The external iliac artery was patent proximally, however, in its midportion, there appeared to be tubular 70% to 80% disease. The right CFA appeared to be widely patent.
At this time, we exchanged out the pigtail catheter for a 6-French 105 cm Terumo sheath. We then proceeded with placement of a long angled stiff Glidewire and a NaviCross catheter into the right common iliac artery. The patient received 10,000 heparin IV with ACTs being checked every 15 minutes thereafter, to maintain an ACT greater than 250. The NaviCross catheter with the 0.035 wire could not cross this area. We tried a Glidewire Gold 0.018 wire. This could not cross this area. We then switched out for a long straight stiff Glidewire, which was successfully traversed this area, and this wire was then placed into the right SFA. The NaviCross catheter, which was angled, was removed. A straight NaviCross catheter was advanced and this successfully made it down to the SFA. Angiogram was obtained, which showed this was a true vessel. We then placed an 0.014 wire into the SFA. We proceeded with PTA first with a 4.0 x 40 mm Boston Scientific stent throughout the external iliac and common iliac arteries. After this was performed, we then proceeded with shock wave atherectomy of the common iliac artery with a shock wave 7.0 x 60 balloon. This was done in multiple sequential inflations this occurred. After this was performed, the balloon was removed. Angiographic images obtained, which showed improved patency of this area with no dissection or perforation.
We then proceeded with stenting. First, we switched out this wire for an 0.035 Glidewire and proceeded with stenting with a Misago 7.0 x 40 mm stent in the external iliac artery. This was deployed successfully. We then decided to dilate this area further with a 6.0 x 60 mm balloon, inflated to 12 atmospheres for 20 seconds' time. After this was performed, angiographic images were obtained, which showed improved patency of this area with no occlusion, perforation, or dissection.
Then, our attention was turned to the common iliac artery. We placed an 8.0 x 37 mm balloon expandable stent in this area and deployed it successfully at 16 atmospheres for 10 seconds. After this was performed, angiographic exam showed improved patency of the area. There was still a ledge of calcium above this previously placed stent. Thus, we placed a proximal stent, 8.0 x 17, in this area and deployed this at 16 atmospheres for 15 seconds. After this was performed, angiographic images obtained, which showed excellent patency of the stented area with no evidence of dissection or perforation. The wire was pulled back. The guide catheter was removed. The left wrist was closed with a radial band.
The patient tolerated the procedure well with no complications.
Of note, the patient had a palpable anterior tibial artery pulse at the end of the procedure, which she did not have at the at the beginning of the procedure.
IMPRESSION: Successful percutaneous transluminal coronary angioplasty and stenting of right occluded common iliac artery and external iliac arteries with self-expanding and balloon-expandable stents, as well as shock wave atherectomy.
PLAN: The patient will have 3 hours of bed rest. Anticipate discharge later this afternoon. The patient has an occluded left external iliac and left CFA. Hopefully, restoring flow in her right leg would provide collateralization to her left leg. If she still has claudication in the left leg, we can potentially bring her back for attempt from the right groin of getting up and over and attempting of potentially atherectomy and DCB of her left CFA and external iliac arteries.
I really would appreciate any help with this. Thanks so much!
INDICATION FOR PROCEDURE: Severe symptomatic claudication.
PROCEDURES:
1. Left radial artery access.
2. Abdominal aortogram.
3. Shockwave atherectomy of right common iliac artery.
4. Percutaneous transluminal coronary angioplasty and stenting of right distal external iliac artery with Misago 7.0 x 60 mm stent.
5. Percutaneous transluminal coronary angioplasty and stenting of right common iliac artery using balloon expandable 8.0 x 37 mm balloon expandable stent.
6. Stenting of right common iliac artery with balloon expandable 8.0 x 17 mm balloon expandable stent.
HISTORY: Briefly, this is a 78-year-old female history of severe claudication, known bilateral iliac/external iliac artery disease. The patient was consented for a peripheral vascular angiogram, plus or minus stenting.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to BCH, where the left wrist was prepped in sterile fashion. After Allen test confirmed patency of ulnar artery using local lidocaine, a 6-French sheath placed in the left radial artery. The patient was given 2000 heparin, 200 mcg of nitroglycerin through the sheath.
A pigtail catheter was advanced over an 0.035 wire to the descending aorta. Abdominal aortogram was obtained, which showed patent distal aorta, patent left common iliac artery ostium. The left internal iliac artery was patent. The left external iliac artery was 100% occluded after its initial takeoff. There was reconstitution of the common femoral artery in its mid femoral head via internal iliac collaterals. The right common iliac artery had an ostial 30% to 40% narrowing. Distal to this, there was aneurysmal formation of the iliac artery with diffuse dissection planes throughout the prox mid common iliac artery. The internal iliac artery was patent. The external iliac artery was patent proximally, however, in its midportion, there appeared to be tubular 70% to 80% disease. The right CFA appeared to be widely patent.
At this time, we exchanged out the pigtail catheter for a 6-French 105 cm Terumo sheath. We then proceeded with placement of a long angled stiff Glidewire and a NaviCross catheter into the right common iliac artery. The patient received 10,000 heparin IV with ACTs being checked every 15 minutes thereafter, to maintain an ACT greater than 250. The NaviCross catheter with the 0.035 wire could not cross this area. We tried a Glidewire Gold 0.018 wire. This could not cross this area. We then switched out for a long straight stiff Glidewire, which was successfully traversed this area, and this wire was then placed into the right SFA. The NaviCross catheter, which was angled, was removed. A straight NaviCross catheter was advanced and this successfully made it down to the SFA. Angiogram was obtained, which showed this was a true vessel. We then placed an 0.014 wire into the SFA. We proceeded with PTA first with a 4.0 x 40 mm Boston Scientific stent throughout the external iliac and common iliac arteries. After this was performed, we then proceeded with shock wave atherectomy of the common iliac artery with a shock wave 7.0 x 60 balloon. This was done in multiple sequential inflations this occurred. After this was performed, the balloon was removed. Angiographic images obtained, which showed improved patency of this area with no dissection or perforation.
We then proceeded with stenting. First, we switched out this wire for an 0.035 Glidewire and proceeded with stenting with a Misago 7.0 x 40 mm stent in the external iliac artery. This was deployed successfully. We then decided to dilate this area further with a 6.0 x 60 mm balloon, inflated to 12 atmospheres for 20 seconds' time. After this was performed, angiographic images were obtained, which showed improved patency of this area with no occlusion, perforation, or dissection.
Then, our attention was turned to the common iliac artery. We placed an 8.0 x 37 mm balloon expandable stent in this area and deployed it successfully at 16 atmospheres for 10 seconds. After this was performed, angiographic exam showed improved patency of the area. There was still a ledge of calcium above this previously placed stent. Thus, we placed a proximal stent, 8.0 x 17, in this area and deployed this at 16 atmospheres for 15 seconds. After this was performed, angiographic images obtained, which showed excellent patency of the stented area with no evidence of dissection or perforation. The wire was pulled back. The guide catheter was removed. The left wrist was closed with a radial band.
The patient tolerated the procedure well with no complications.
Of note, the patient had a palpable anterior tibial artery pulse at the end of the procedure, which she did not have at the at the beginning of the procedure.
IMPRESSION: Successful percutaneous transluminal coronary angioplasty and stenting of right occluded common iliac artery and external iliac arteries with self-expanding and balloon-expandable stents, as well as shock wave atherectomy.
PLAN: The patient will have 3 hours of bed rest. Anticipate discharge later this afternoon. The patient has an occluded left external iliac and left CFA. Hopefully, restoring flow in her right leg would provide collateralization to her left leg. If she still has claudication in the left leg, we can potentially bring her back for attempt from the right groin of getting up and over and attempting of potentially atherectomy and DCB of her left CFA and external iliac arteries.
I really would appreciate any help with this. Thanks so much!
