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Hi! I need a little guidance on what little documentation I have for the case below. Please help!
Indication
Lifestyle limiting claudication
Rutherford Class:4
“Conscious sedation was administered by qualified nursing personnel under continuous hemodynamic monitoring, Duration 69 Min, starting at 9: 15 and ending at 10: 20.
A total seventy-five mcg of fentanyl and one mg midazolam were administered.”
Contrast 160 cc.
Air kerma 860
Final ACT182
Procedure
Low Ext Angio
Low Ext Intervention
Access Site: Right common femoral
Closure Device: Unable to deploy Perclose we used six French Angio-Seal. There was a hematoma during the exchange which was expressed and manual pressure was applied for 20 minutes
ANGIOGRAM FINDINGS
Patent Outflow Arteries:
Right common iliac artery patent with mild diffuse atherosclerosis.
Right external iliac artery has severe disease in the degree above 90%.
Patent right common femoral artery and right profunda arteries.
SFA Left
atent with evidence of 70% distal SFA disease at the level of the adductor canal–focal lesion.
6.0 French Terumo sheath was used to introduce a guiding wire into the common iliac then the external iliac down to the SFA we used a 6.0 balloon, this was followed by 7.0 x 16 mm EV three self-expanding stent that was deployed at the external iliac artery and then postdilated with a 7.0 balloon. Then we directed a 4.0x20 balloon to the distal SFA for a severe lesion at the level of the adductor canal and balloon angioplasty was performed and obtained excellent result with less than 10% residual
Indication
Lifestyle limiting claudication
Rutherford Class:4
“Conscious sedation was administered by qualified nursing personnel under continuous hemodynamic monitoring, Duration 69 Min, starting at 9: 15 and ending at 10: 20.
A total seventy-five mcg of fentanyl and one mg midazolam were administered.”
Contrast 160 cc.
Air kerma 860
Final ACT182
Procedure
Low Ext Angio
Low Ext Intervention
Access Site: Right common femoral
Closure Device: Unable to deploy Perclose we used six French Angio-Seal. There was a hematoma during the exchange which was expressed and manual pressure was applied for 20 minutes
ANGIOGRAM FINDINGS
Patent Outflow Arteries:
Right common iliac artery patent with mild diffuse atherosclerosis.
Right external iliac artery has severe disease in the degree above 90%.
Patent right common femoral artery and right profunda arteries.
SFA Left
atent with evidence of 70% distal SFA disease at the level of the adductor canal–focal lesion.6.0 French Terumo sheath was used to introduce a guiding wire into the common iliac then the external iliac down to the SFA we used a 6.0 balloon, this was followed by 7.0 x 16 mm EV three self-expanding stent that was deployed at the external iliac artery and then postdilated with a 7.0 balloon. Then we directed a 4.0x20 balloon to the distal SFA for a severe lesion at the level of the adductor canal and balloon angioplasty was performed and obtained excellent result with less than 10% residual