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Is anything billable?


Columbia, SC
Best answers
REASON FOR PROCEDURE: Known coronary disease, bypass surgery 2009 admitted with chest pain, acute myocardial infarction.

PROCEDURE RESULTS: Access was attempted right femoral artery.The patient
has a history of aortobifem. The graft was accessed. The introducer was
placed as wire would not advance into the abdominal aorta. Through the
introducer imaging was performed. Imaging showed a very tortuous iliac
anatomy with large ulcerated plaque and small vessel tie-ins which favored
the wire. Multiple attempts were made with multiple wires including J-wire,
Wholey wire and Glidewire. All favored non-grafted vessels and difficult to
ascend to the descending aorta. Multiple views were attempted to clarify
anatomy in this attempt. Before doing so it was assumed access would be
feasible and after initial imaging the introducer was changed over a wire for
a 5-French sheath. A 5-French sheath remained in when attempt was made from
the left. Anatomy was clarified via fluoroscopy. Several attempts were made
to have access to arterial-graft vessels. Flashback was obtained, which was
brisk although with multiple attempts wires would not pass on the level of
the iliac crest. An introducer was advanced. With this no backflow of blood
was attain. Slow pullback of this sheath initially did not get pulled back
until near the access point suggesting a possible placement of the introducer
into nonvascular structures or stump of pre-existing vessels. In any attempt
the wire would not pass into the descending aorta. As well of course we were
unable to advance the catheter to the point where contralateral antegrade
imaging could be performed. The arms were inspected and felt to be
relatively small. Radial arteries and brachial arteries relatively small and
not excluding access, although given overall clinical scenario and 2 access
points canalized and the decision was made to stop here with consideration for medical management and re-investigate if that appears to be problematic.

CONCLUSIONS: Multiple attempts failing to reach the descending aorta, both
right and left with multiple catheters and wires. Access unobtainable to the
descending aorta due to serious and difficult tortuous iliac and graft
anatomy from aortobifem. Arms were relatively small with and given 2 access
points the decision was made to treat medically prior to attempting other
access options such as brachial or radial or re-attempt at the groin anatomy
possibly with some information from pelvic CT arteriogram.
Best answers
that is tough, he did get non-selective access in each femoral so 36140x2. and he definitely imaged the right iliac but it isn't clear if he did an injection on the left side. so either 75710 or 75716. might also want to consider modifier 22, definitely an extraordinary amount of work.