csorensen21@yahoo.com
Networker
- Messages
- 70
- Best answers
- 0
Can someone please help me code this complex case? I am struggling. Thanks so much!
INDICATIONS
Patient was referred for LE angiography to assess the coronary anatomy . Indications for the procedure include: Bilateral claudication, worse on the right.
Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Patient was brought to the cath lab after IV hydration was begun and oral premedication was given. Patient was further sedated with fentanyl and versed. Patient was prepped and draped in the usual manner. Using the modified Seldinger access technique, a 6 French sheath was placed in the left femoral artery.
A 6 French LIMA catheter was used to gain access to the right iliofemoral system. A 0.035 glide advantage wire was advanced to the mid SFA then the LIMA and that she is over replaced with a long 6 French sheath which was lodged into the proximal right SFA. Initial angiography revealed evidence of chronic total occlusion of the distal right SFA with heavy calcification. There is reconstitution on the distal SFA. The popliteal was patent with chronic total occlusion of a segment of the right posterior tibial artery and most of the anterior tibial artery but patency of the right peroneal artery.
I proceeded with crossing the lesion using the glide advantage wire bent along with a microcatheter. I was able to get to the distal calf without any problems and without extension of the occlusion. The wire was lodged in the infrapopliteal segments. The wire was replaced with a peripheral Viper wire.
I proceeded with CSI atherectomy of the right SFA. I was very cautious going slowly across the occlusion using a slow speed forward then backwards. I then proceeded with medium speed in the same fashion, but then I kept the device distal to the occlusion. There was evidence of a channel within the occlusion. I proceeded with final atherectomy proceeding backwards with high-speed from the distal to the proximal segment. Suddenly the device stopped and we could not move the bur. We found out that the device was cut off within the sheath. I used multiple maneuvers with coronary balloons over coronary wires distal to the device as I tried to pull the device back enough into the sheath. I was able to get the proximal end of the cut device into the proximal end of my sheath in the groin and I was able to pull the device all the way out. Unfortunately we were left with the Viper wire partially in the sheath along its distal end. Dr. ______ came to help and both of us were unable to snare the wire either inside the sheath or as we pulled the sheath back and left the wire in the SFA. Dr. ______ from interventional radiology assisted us and was able to snare the wire back into the sheath halfway into the sheath and then using a long 4.0×40 mm coronary balloon inflated inside the sheath with a long coronary wire advanced into the distal SFA we pulled the entire system including the sheath. We were able to retrieve the entire Viper wire. We were left with the coronary wire into the right SFA through the left femoral artery. We were able to place a 6 a short 6 French sheath and then replace the coronary wire with the glide advantage wire using a 4 French glide catheter. Along the glide advantage I was able then to take the 6 French long sheath back into the proximal right SFA. I was able to engage the wire into the distal infrapopliteal segments. I proceeded with balloon angioplasty of the distal SFA that had been atherectomized. I used a 5.0×80 mm Armada balloon for angioplasty of the lesion with 2 inflations at 8 atm for 1 minute each. I then proceeded with PTA of the entire lesion using a 6.0×150 mm Lutonics drug-eluting balloon for 2 minutes at 8 atm. Final angiography revealed evidence of wide patency of the right superficial femoral artery with minimal residual and dissection thrombus or staining. Initially there was decreased flow along the vessel that was reversed after the injection of intra-arterial nitride. The infra popliteal segments were unchanged. At the end of the procedure I proceeded with angiography of the left superficial femoral artery popliteal artery and infrapopliteal vessels using the 6 French left femoral arterial sheath.
At the end of the procedure the sheath was removed and hemostasis to the left groin was achieved using the Angio-Seal device. The patient tolerated the procedure well and left the Cath Lab in stable condition.
Heparin was given at the beginning and throughout the procedure to maintain ACT over 240.
Vascular Surgery Dr. ____ was consulted and was onstandby ready for OR if needed.
Estimated Blood Loss: less than 10 mL
Specimens Collected: None
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable
Condition: stable
Moderate conscious sedation was administered by a qualified nursing professional under Continuous hemodynamic monitoring starting at 7:24 AM , and ending at 11:40 AM
Total IV Fentanyl: 200 mcg
Total IV Versed: 4 mg
Contrast: 90 cc Isovue
Air Kerma: 612 MGY
Nurse:
Impression:
Bilateral claudication, worse on the right than the left.
Evidence of chronic total occlusion of the distal right SFA with a very heavily calcified segment, status post successful CSI atherectomy and PTA using drug-eluting balloon with an excellent result. The procedure was complicated by device malfunction and breaking of the device and the Viper wire both of which were retrieved successfully.
Evidence of right sided infrapopliteal disease with chronic total occlusion of most of the right anterior tibial artery and a segment of the right posterior tibial artery but patency of the right peroneal artery.
Evidence of severe stenosis involving the left distal SFA with calcification. There was evidence of occlusion of most of the right anterior tibial artery with stenosis of a segment of the right posterior tibial artery and patency of the peroneal artery.
Treatment:
ASA
Will start low dose Xarelto
Statins
Continue current medical therapy
INDICATIONS
Patient was referred for LE angiography to assess the coronary anatomy . Indications for the procedure include: Bilateral claudication, worse on the right.
Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Patient was brought to the cath lab after IV hydration was begun and oral premedication was given. Patient was further sedated with fentanyl and versed. Patient was prepped and draped in the usual manner. Using the modified Seldinger access technique, a 6 French sheath was placed in the left femoral artery.
A 6 French LIMA catheter was used to gain access to the right iliofemoral system. A 0.035 glide advantage wire was advanced to the mid SFA then the LIMA and that she is over replaced with a long 6 French sheath which was lodged into the proximal right SFA. Initial angiography revealed evidence of chronic total occlusion of the distal right SFA with heavy calcification. There is reconstitution on the distal SFA. The popliteal was patent with chronic total occlusion of a segment of the right posterior tibial artery and most of the anterior tibial artery but patency of the right peroneal artery.
I proceeded with crossing the lesion using the glide advantage wire bent along with a microcatheter. I was able to get to the distal calf without any problems and without extension of the occlusion. The wire was lodged in the infrapopliteal segments. The wire was replaced with a peripheral Viper wire.
I proceeded with CSI atherectomy of the right SFA. I was very cautious going slowly across the occlusion using a slow speed forward then backwards. I then proceeded with medium speed in the same fashion, but then I kept the device distal to the occlusion. There was evidence of a channel within the occlusion. I proceeded with final atherectomy proceeding backwards with high-speed from the distal to the proximal segment. Suddenly the device stopped and we could not move the bur. We found out that the device was cut off within the sheath. I used multiple maneuvers with coronary balloons over coronary wires distal to the device as I tried to pull the device back enough into the sheath. I was able to get the proximal end of the cut device into the proximal end of my sheath in the groin and I was able to pull the device all the way out. Unfortunately we were left with the Viper wire partially in the sheath along its distal end. Dr. ______ came to help and both of us were unable to snare the wire either inside the sheath or as we pulled the sheath back and left the wire in the SFA. Dr. ______ from interventional radiology assisted us and was able to snare the wire back into the sheath halfway into the sheath and then using a long 4.0×40 mm coronary balloon inflated inside the sheath with a long coronary wire advanced into the distal SFA we pulled the entire system including the sheath. We were able to retrieve the entire Viper wire. We were left with the coronary wire into the right SFA through the left femoral artery. We were able to place a 6 a short 6 French sheath and then replace the coronary wire with the glide advantage wire using a 4 French glide catheter. Along the glide advantage I was able then to take the 6 French long sheath back into the proximal right SFA. I was able to engage the wire into the distal infrapopliteal segments. I proceeded with balloon angioplasty of the distal SFA that had been atherectomized. I used a 5.0×80 mm Armada balloon for angioplasty of the lesion with 2 inflations at 8 atm for 1 minute each. I then proceeded with PTA of the entire lesion using a 6.0×150 mm Lutonics drug-eluting balloon for 2 minutes at 8 atm. Final angiography revealed evidence of wide patency of the right superficial femoral artery with minimal residual and dissection thrombus or staining. Initially there was decreased flow along the vessel that was reversed after the injection of intra-arterial nitride. The infra popliteal segments were unchanged. At the end of the procedure I proceeded with angiography of the left superficial femoral artery popliteal artery and infrapopliteal vessels using the 6 French left femoral arterial sheath.
At the end of the procedure the sheath was removed and hemostasis to the left groin was achieved using the Angio-Seal device. The patient tolerated the procedure well and left the Cath Lab in stable condition.
Heparin was given at the beginning and throughout the procedure to maintain ACT over 240.
Vascular Surgery Dr. ____ was consulted and was onstandby ready for OR if needed.
Estimated Blood Loss: less than 10 mL
Specimens Collected: None
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable
Condition: stable
Moderate conscious sedation was administered by a qualified nursing professional under Continuous hemodynamic monitoring starting at 7:24 AM , and ending at 11:40 AM
Total IV Fentanyl: 200 mcg
Total IV Versed: 4 mg
Contrast: 90 cc Isovue
Air Kerma: 612 MGY
Nurse:
Impression:
Bilateral claudication, worse on the right than the left.
Evidence of chronic total occlusion of the distal right SFA with a very heavily calcified segment, status post successful CSI atherectomy and PTA using drug-eluting balloon with an excellent result. The procedure was complicated by device malfunction and breaking of the device and the Viper wire both of which were retrieved successfully.
Evidence of right sided infrapopliteal disease with chronic total occlusion of most of the right anterior tibial artery and a segment of the right posterior tibial artery but patency of the right peroneal artery.
Evidence of severe stenosis involving the left distal SFA with calcification. There was evidence of occlusion of most of the right anterior tibial artery with stenosis of a segment of the right posterior tibial artery and patency of the peroneal artery.
Treatment:
ASA
Will start low dose Xarelto
Statins
Continue current medical therapy