Lower extremity arterial angiography procedure

Jane5711

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Can anyone help with coding?

PROCEDURES PERFORMED:
1. Bilateral lower extremity arterial angiography with runoff.
2. Angioplasty of the right popliteal artery with a 5.0/40-mm balloon with
the suboptimal angioplasty results.
3. Stenting of the right popliteal artery with a 6.0/60-mm Armada balloon.
4. Angioplasty of the right anterior tibial artery with a 4.0/40-mm
balloon.
5. Angioplasty of the right peroneal artery with a 4.0/40-mm balloon and
2.5/120-mm balloon.
6. Thrombolysis of the right popliteal artery and distal to it with tPA
thrombolysis - D1.

INDICATIONS:
1. Rest pain with severe arterial insufficiency of the right lower
extremity.
2. Peripheral artery disease with total occlusion of the right popliteal
artery.

DESCRIPTION OF PROCEDURE: After the informed consent was obtained, the
patient was prepped and draped in the usual sterile fashion. Lidocaine 2
percent was used for local anesthesia in the left groin, vascular access was
obtained in the left femoral artery, and over a guidewire, 6-French long
angiographic sheath was placed in the left femoral artery.

A 5-French pigtail catheter was introduced over a guidewire into the distal
abdominal aorta and distal abdominal aortogram with bilateral lower
extremity arterial angiography with the runoff was performed to visualize
both lower extremity arteries.

Then, the pigtail catheter was removed.

Using a 5-French universal flush catheter and a Glidewire, the long arrow
sheath was advanced into the right common femoral and right superficial
femoral artery.

The first subsequent angiography of the right superficial femoral artery to



visualize the right popliteal artery was performed.

Then, heparin 10,000 units were given and subsequently another 5000 units of
heparin x2 were also given during the procedure.

Using angled Terumo glidewire and with the help of the Quick-Cross catheter,
the occlusion in the right popliteal artery was crossed. The Quick-Cross
catheter was advanced in the right peroneal artery and angiography of the
right popliteal artery was performed which showed the patency of the mid
distal portion of the right popliteal artery with significant lesions in the
midportion of the right popliteal artery.

Then, a 5.0/40-mm Armada balloon was advanced into the proximal portion of
the right popliteal artery, was used to dilate the lesion at 8 atmospheres.
The balloon was advanced further in the mid portion of the right popliteal
artery and then distal portion of the right popliteal artery with sequential
inflations at 8 atmospheres.

The balloon was then removed. Angiography revealed that the right popliteal
artery is now patent with significant amount of thrombus in the right
popliteal artery.

After the angioplasty of the right popliteal artery, in its proximal
portion, there was a significant lesion noted without any thrombus in that
section.

Hence, a 6.0/60-mm Absolute Pro stent was advanced into the proximal and mid
portion of the right popliteal artery and with the distal portion of the
stent about 1 to 2 cm proximal to the joint space is where the stent was
deployed. The stent catheters delivery system was removed after the
deployment of the stent.

The 6.0/60-mm balloon was advanced to post-dilate the stent at 8 atmospheres
with good results, but distal to the stent and in the distal portion of the
right popliteal artery, there is still significant amount of thrombus noted.

Over the existing wire in the right peroneal artery, a 2.5/120-mm balloon
was advanced and was used to dilate the distal portion of the right peroneal
artery followed by midportion of the right popliteal artery, followed by
proximal portion of the right peroneal artery. The balloon was inflated up
to 14 atmospheres in sequential inflations.

The balloon was removed and focal 50 to 70 percent stenosis noted in the
midportion of the right peroneal artery, but there was a significant
thrombus in the proximal portion of the right popliteal artery.

Hence, a 4.0/40-mm Armada balloon was reintroduced into the right peroneal
artery in its proximal portion and was used to dilate it at 10 to 14
atmospheres. The balloon was removed and then a Pronto catheter was inserted


to the tibioperoneal trunk and suction thrombectomy was performed x3. Some
improvement of this thrombus was noted in the distal portion of the right
popliteal artery, but there was still significant amount of thrombus
present.

Using the help of a glide catheter, 0.014 Command wire was then used to
cross the lesion in the right anterior _____ tibial artery.

A 4.0/40-mm balloon was then advanced over the guidewire into the right
anterior tibial artery and was used to dilate the right anterior tibial
artery at 10 atmospheres. The balloon was then removed. Then, angiographic
images were obtained.

At this point, the right anterior tibial artery now was noted to be patent
except for the thrombus in its proximal portion. There was a similar
thrombus in the right peroneal artery in its proximal portion. The right
posterior tibial artery is totally occluded with a collateral arising from
the right superficial femoral artery supplying the distal portion of the
right posterior tibial artery. Thus, there is a 3-vessel runoff to the right
lower extremity, but significant thrombus noted in the right anterior tibial
artery and right peroneal artery in its proximal portion as well as
significant thrombus noted in the distal portion of the right popliteal
artery.

Hence, with the help of the Quick-Cross catheter which was advanced to the
proximal portion of the right popliteal artery, 4 mg of tPA/Activase was
infused directly into the right popliteal artery.

Then, an infusion catheter was advanced into the midportion of the right
popliteal artery and tPA infusion was started at a dose of 1 mg per hour. At
this point, the arterial sheath was sutured in place. The patient was
transferred in a stable condition to the floor for further care with no
complications.

RESULTS:
1. Distal abdominal aorta: The distal abdominal aorta bifurcates into 2
common iliac arteries. The distal abdominal aorta is of normal size.
2. Common iliac arteries:
a. The right common iliac artery has no significant disease and
bifurcates into internal and external iliac arteries.
b. Left common iliac artery: Left common iliac artery has no
significant disease. It bifurcates into the left external iliac and
left internal iliac arteries.
3. Internal iliac arteries: Both right and left internal iliac arteries
have no significant disease.
4. External iliac arteries: Both right and left external iliac arteries
have no significant disease and continue on as the common femoral
arteries.
5. Common femoral arteries: Both right and left common femoral arteries

have no significant disease and bifurcate into superficial femoral and
deep femoral arteries.
6. Deep femoral arteries: Both right and left deep femoral arteries have no
significant disease.
7. Superficial femoral arteries: Both the right and left superficial
femoral arteries have mild disease without any high-grade focal
stenosis.
8. Popliteal arteries.
a. Left popliteal artery: The left popliteal artery has no significant
disease, it continues on behind the knee, there is an artificial
knee on the left side and below the knee joint, the left popliteal
artery trifurcates into peroneal trunk and the right anterior tibial
arteries.
b. Right popliteal artery: The right popliteal artery is totally
occluded in its proximal portion. There is a collateral from the
right superficial femoral artery supplying the distal portion of the
right posterior tibial artery.
9. Left trifurcation arteries.
a. The trifurcation artery on the left side consists of the left
anterior tibial artery and the left peroneal trunk.
b. The left anterior artery is totally occluded in its mid distal
portion.
c. The left peroneal trunk gives rise to left peroneal artery and the
left posterior tibial artery. The left posterior tibial artery is
patent up to the ankle and the left peroneal artery is patent also
with mild-to-moderate diffuse disease in its distal portion. There
is 2-vessel runoff to the left ankle.
10. Trifurcation arteries on the right side:
a. The trifurcation arteries on the right side consists of the right
anterior tibial artery and right peroneal trunk, so both the right
anterior tibial artery and right tibioperoneal trunk have
significant amount of thrombus noted in them.
b. The right anterior tibial artery beyond the thrombus in its proximal
portion is widely patent and runs up to the ankle.
c. The right peroneal artery has a thrombus in its proximal portion and
mid portion has high-grade stenosis, which underwent angioplasty
with a residual 50 percent stenosis.
d. The right posterior tibial artery is totally occluded in its
proximal to midportion, but the distal portion is filled by
collaterals coming from the right superficial femoral artery.
e. Thus, there is a 3-vessel runoff to the right ankle, but there is
sluggish flow in this vessel secondary to thrombus burden in the
proximal portion of these vessels.

IMPRESSION:
1. Severe peripheral artery disease with total occlusion of the right
popliteal artery with large amount of thrombus burden in the right
popliteal artery with significant thrombus still noted in the right
anterior tibial artery and right peroneal artery despite angioplasty and

suction thrombectomy as well as despite a bolus of tPA in the right
popliteal artery.
2. No significant disease of the left lower extremity artery with a
2-vessel runoff to the ankle with a patent left posterior tibial artery
and left peroneal artery with the mid distal portion of left anterior
tibial artery occluded.
3. Three-vessel runoff to the right ankle with significant thrombus burden
in the right anterior tibial artery and right peroneal artery and
totally occluded proximal midportion of the right posterior tibial
artery which is filled by collaterals in its distal portion from the
right superficial femoral artery.
4. Prior to the procedure, there was total occlusion of the right popliteal
artery.
5. Post procedure, after angioplasty followed by stenting of the right
popliteal artery, the right popliteal artery in its proximal midportion
is patent, but the distal portion is severely compromised with a
thrombus burden in it and yet there is flow to both anterior tibial and
posterior peroneal arteries through the thrombus itself. Infusion
catheter is in place in the right popliteal artery in its distal portion
infusing tPA.

PLAN:
1. The patient will be kept overnight with tPA infusion in the right
popliteal artery and the patient will be brought back for angiography of
the right popliteal artery and the distal arteries in 24 hours. Further
management will be based on findings at that time.
2. The patient will be kept on low-dose heparin drip as well as currently
on infusion with tPA at 1 mg an hour for about 24 hours.

I come up with 75716, 26, 37226 RT and 37184?
Thanks.
 

Jim Pawloski

True Blue
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Location
Ann Arbor
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After reviewing the report further I think the codes should be 37226rt, 37228rt, 37232rt, 75716,26
Appreciate any help at all!!!! Jim (any ideas)

Hello,

I agree with your 37226-rt, 37228-rt, and 37232-rt and 75716-26-59. I would also code 37186 for the suction thrombectomy, and 37221 for the infusion of thrombolytics.

Hope that helps,
Jim
 
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