bhargavi
Guru
CLINICAL INDICATIONS
Recurrent claudication symptoms involving the right lower extremity.
CLINICAL HISTORY
Mr.is a morbidly obese 53 years old man with a history of peripheral
arterial disease and prior stenting of the right superficial femoral artery,
hypertension, hyperlipidemia, arthritis and active tobacco abuse. He recently
returned to my office for further evaluation due to recurrent claudication
symptoms in his right leg. His ABI study was unremarkable but his symptoms
were convincing enough to warrant repeating noninvasive imaging with CTA. This
revealed a 40 percent stenosis in the segment of SFA just proximal to the
stented segment with significant inferopopliteal disease bilaterally. Due to
his ongoing symptoms, he was referred for repeat peripheral vascular
angiography and possible intervention.
TECHNIQUE
After obtaining informed consent, the patient was prepped and draped in the
usual fashion. Approximately 10 milliliters of two percent Lidocaine anesthesia
was administered to the left groin prior to placement of the arterial sheath.
Under fluoroscopic guidance and using the modified Seldinger technique, a five
French arterial sheath was placed via the left femoral artery. We then obtained
a five French Contra catheter and advanced it into the distal abdominal aorta.
We performed nonselective digital subtraction angiography of the abdominal
aorta with bilateral ileofemoral run off. This revealed a widely patent and non
diseased distal abdominal aorta and bilateral common external and internal
iliac vessels to the level of the common femoral vessels bilaterally.
We then obtained a 180 centimeters 0.035 inch angle Zip wire and with the
assistance of the Zip wire, advanced the Contra catheter into the distal common
femoral artery on the right. We then performed selective right lower extremity
digital subtraction angiography through this catheter. This revealed a patent
common superficial and profundus femoris artery. In the mid to distal SFA,
above the previously stented segment, there is an area of smooth, tandem 30
percent disease. The stent within the SFA was widely patent without evidence
for in stent restenosis, dissection, thrombosis, spasm or occlusion. The
proximal popliteal just below this stented area had a smooth 20 percent
stenosis. The behind and below the knee popliteal was widely patent. The
anterior tibial vessel was large and widely patent, crossing the ankle mortise
and supplying blood flow to the foot. The tibial peroneal trunk was patent with
perhaps 25 percent disease. The peroneal vessel was widely patent and crossed
the ankle mortise as well. The posterior vessel was occluded in the mid part
of the calf but reconstituted above the ankle and was filled retrogradely from
collaterals from the anterior tibial and peroneal vessels. Given the finding
of no substantial disease and right lower extremity run off, we elected not to
attempt any interventional procedure.
The Contra catheter was then withdrawn over the Zip wire and we performed
selective left lower extremity digital subtraction angiography. This again
revealed a widely patent common superficial and profundus femoris arteries with
approximately 30 percent distal SFA stenosis at the level of the adductor
canal. The popliteal artery was patent in its proximal, mid and distal
segments. The tibial peroneal trunk was again patent with wide patency of the
posterior tibial vessel which crossed the ankle mortise into the foot. The
peroneal vessel was relatively small and occluded in the mid vessel. The
anterior tibial vessel was large and free of significant disease crossing the
ankle mortise into the foot.
Nonselective injection of the ileofemoral system on the left revealed
acceptable position of the arterial sheath in the distal common femoral artery
above the common femoral bifurcation. Therefore, we utilized a six French
Angio-Seal to afford hemostasis. The patient was then transferred to the
recovery area in stable condition.
IMPRESSION
1. Mild disease of right SFA and proximal popliteal with widely patent SFA
stent.
2. Brisk two vessel run off below the knee on the right.
3. Mild disease of SFA on the left with brisk two vessel run off below the
knee on the left.
4. Status post Angio-Seal placement.
PLAN
1. Medical therapy.
2. Search for other causes of discomfort.
thanks in advance
should i do 75630 or 75716,75625 someone told me that 75716,75625 gets paid more vs 75630 for facility lab. although i dont see any description of renals for abd aorta so confused about billing 75716
Recurrent claudication symptoms involving the right lower extremity.
CLINICAL HISTORY
Mr.is a morbidly obese 53 years old man with a history of peripheral
arterial disease and prior stenting of the right superficial femoral artery,
hypertension, hyperlipidemia, arthritis and active tobacco abuse. He recently
returned to my office for further evaluation due to recurrent claudication
symptoms in his right leg. His ABI study was unremarkable but his symptoms
were convincing enough to warrant repeating noninvasive imaging with CTA. This
revealed a 40 percent stenosis in the segment of SFA just proximal to the
stented segment with significant inferopopliteal disease bilaterally. Due to
his ongoing symptoms, he was referred for repeat peripheral vascular
angiography and possible intervention.
TECHNIQUE
After obtaining informed consent, the patient was prepped and draped in the
usual fashion. Approximately 10 milliliters of two percent Lidocaine anesthesia
was administered to the left groin prior to placement of the arterial sheath.
Under fluoroscopic guidance and using the modified Seldinger technique, a five
French arterial sheath was placed via the left femoral artery. We then obtained
a five French Contra catheter and advanced it into the distal abdominal aorta.
We performed nonselective digital subtraction angiography of the abdominal
aorta with bilateral ileofemoral run off. This revealed a widely patent and non
diseased distal abdominal aorta and bilateral common external and internal
iliac vessels to the level of the common femoral vessels bilaterally.
We then obtained a 180 centimeters 0.035 inch angle Zip wire and with the
assistance of the Zip wire, advanced the Contra catheter into the distal common
femoral artery on the right. We then performed selective right lower extremity
digital subtraction angiography through this catheter. This revealed a patent
common superficial and profundus femoris artery. In the mid to distal SFA,
above the previously stented segment, there is an area of smooth, tandem 30
percent disease. The stent within the SFA was widely patent without evidence
for in stent restenosis, dissection, thrombosis, spasm or occlusion. The
proximal popliteal just below this stented area had a smooth 20 percent
stenosis. The behind and below the knee popliteal was widely patent. The
anterior tibial vessel was large and widely patent, crossing the ankle mortise
and supplying blood flow to the foot. The tibial peroneal trunk was patent with
perhaps 25 percent disease. The peroneal vessel was widely patent and crossed
the ankle mortise as well. The posterior vessel was occluded in the mid part
of the calf but reconstituted above the ankle and was filled retrogradely from
collaterals from the anterior tibial and peroneal vessels. Given the finding
of no substantial disease and right lower extremity run off, we elected not to
attempt any interventional procedure.
The Contra catheter was then withdrawn over the Zip wire and we performed
selective left lower extremity digital subtraction angiography. This again
revealed a widely patent common superficial and profundus femoris arteries with
approximately 30 percent distal SFA stenosis at the level of the adductor
canal. The popliteal artery was patent in its proximal, mid and distal
segments. The tibial peroneal trunk was again patent with wide patency of the
posterior tibial vessel which crossed the ankle mortise into the foot. The
peroneal vessel was relatively small and occluded in the mid vessel. The
anterior tibial vessel was large and free of significant disease crossing the
ankle mortise into the foot.
Nonselective injection of the ileofemoral system on the left revealed
acceptable position of the arterial sheath in the distal common femoral artery
above the common femoral bifurcation. Therefore, we utilized a six French
Angio-Seal to afford hemostasis. The patient was then transferred to the
recovery area in stable condition.
IMPRESSION
1. Mild disease of right SFA and proximal popliteal with widely patent SFA
stent.
2. Brisk two vessel run off below the knee on the right.
3. Mild disease of SFA on the left with brisk two vessel run off below the
knee on the left.
4. Status post Angio-Seal placement.
PLAN
1. Medical therapy.
2. Search for other causes of discomfort.
thanks in advance
should i do 75630 or 75716,75625 someone told me that 75716,75625 gets paid more vs 75630 for facility lab. although i dont see any description of renals for abd aorta so confused about billing 75716
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