Question Lower extremity revascularization procedures

carelitz

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I am hopefully getting the hang of these new procedures but would love if someone would double check me. The report is very long and detailed so I hope I captured all charges! Thanks for any help!

I came up with: (DX of I70.211)

75710 2659RT (Lower extremity angiogram)
37252, 37253, 37253 (IVUS x3)
37184, 37185 (Mechanical thrombectomy of FEM-POP) (Mechanical thrombectomy of TIB-PER)
37226 (Stent to SFA)
37228 (PTA of Peroneal artery)
99152 (Moderate sedation)


PROCEDURE:

1. Right lower extremity angiogram:
2. Right superficial femoral artery/popliteal artery mechanical
thrombectomy, angioplasty, and stent.
3. Mechanical thrombectomy and angioplasty of the right peroneal
artery.
4. Intravascular ultrasound of the right peroneal artery, popliteal,
superficial femoral artery, and external iliac artery.


INDICATIONS FOR PROCEDURE: This is a patient with severe peripheral
vascular disease with previous history of occlusion of right SFA,
popliteal artery with angioplasty in 2016, followed by stent in 2017,
history of restenosis, and implantation of drug-eluting stent to the right
SFA in 01/2020. She was doing well for 7 months, but redeveloped severe
right leg pain, including night pain, consistent with critical limb
ischemia. A followup ultrasound showed occlusion from distal common
femoral artery and of entire SFA and popliteal artery. Pros and cons of
procedure were discussed, and consent was obtained.

TECHNIQUE: Vascular access obtained to the left common femoral artery
with micropuncture kit and modified Seldinger technique, and 6-French 45
cm sheath was advanced and positioned initially to the proximal left
common iliac artery. Then with the support of 6-French IM catheter, the
Glidewire was navigated to the right iliac and then deep femoral artery,
the catheter was exchanged to the 5-French Omni Flush catheter and then
wire was exchanged to 300 cm SupraCore wire, which allowed us to safely
advance the 6-French 45 cm sheath across the aortic bifurcation and placd
it to the distal right external iliac artery. This catheter was used for
the initial angiogram and intervention, additional right lower extremity
angiogram was obtained through the 5-French NaviCross catheter, positioned
to the distal right popliteal artery crossing the lesion.

Moderate sedation was provided with IV Versed and IV fentanyl, local
anesthesia with topical left groin, lidocaine 2 percent 15 mL.

Moderate sedation was provided with IV Versed and fentanyl.

Blood loss was estimated at 300 mL, considering mechanical thrombectomy
use.

Anticoagulation with IV heparin for therapeutic ACT more than 250.

Manual management of access site.

HEMODYNAMICS: Arterial pressure was 125/70 mmHg.

BASELINE ANGIOGRAM RIGHT LOWER EXTREMITY:

1. Right common iliac artery is a medium size, mildly calcified vessel
with moderate luminal irregularities without significant stenosis.
2. Right hypogastric artery is a small medium sized vessel, patent.
3. Right external iliac artery has widely patent stent, there is not
more than 10-20 percent stenosis of the vessel.
4. Right common femoral artery is practically nonexistent. It is less
than a centimeter long, it gives medium sized deep femoral artery,
which has about 60-70 percent ostial stenosis, and then stents in
entire right superficial femoral artery and proximal-mid popliteal
artery all occluded with evidence of minimal contrast entering the
proximal stent, and then reconstitution of most distal popliteal
artery via the collaterals through the deep femoral system and
respective antegrade filling of the patent anterior tibial artery,
which is normal sized vessel with mild luminal irregularities, but
continues in dorsalis pedis.
5. Tibioperoneal trunk is a medium-sized vessel, patent.
6. Peroneal artery is a medium-sized vessel, completely patent
proximally, mid portion has 60-70 percent stenosis, distal portion
has 60-70 percent stenosis. The posterior tibial artery is occluded
in proximal and midportion, but reconstitutes via collateral from
the peroneal artery distally.

Intravascular ultrasound, mechanical thrombectomy, angioplasty of the
right superficial femoral artery and popliteal artery and stent:
Initially, we crossed with moderate difficulty the occluded stents with
NaviCross catheter and Advantage wire. Beyond the stent in the distal
popliteal artery, the chronic total occlusion was most complex, initially
we crossed it subintimally, but then with the use of angled NaviCross
catheter and Advantage 300 cm angled wire, I was able to navigate the
system luminally and we advanced the NaviCross catheter to the distal
popliteal artery, exchanged the wire to the 300 cm Grand Slam wire, which
was navigated to the peroneal artery, and NaviCross catheter was removed.
We then used 0.014 Philips intravascular ultrasound system, the catheter
was positioned to the proximal right peroneal artery, pullback was
performed to the right external iliac artery and all recordings obtained
and analyzed.


INTRAVASCULAR ULTRASOUND FINDINGS:

1. Peroneal artery is a small 2.6 x 2.9 diameter vessel with moderate
plaque without obstructive stenosis.
2. Tibioperoneal tract is a 3 x 3.1 mm vessel with moderate plaque, no
obstructive stenosis.
3. Popliteal artery is 3.8 x 3.8 in the distal portion with 82 percent
stenosis and then mid and distal popliteal artery is in-stent
occluded with a stent diameter of 4.8 x 4.9 mm. The wire crossed
entire stented segment and native vessel intraluminally.
4. Superficial femoral artery is with various diameter, mid and distal
portion, it is a 4.8 x mm occluded with areas of some clot and
hibernation and in proximal portion, it is 6.5 x 6.3 with areas of
clot.
5. Right external iliac artery was a medium-sized vessel, measured 6.9
x 7 mm without evidence of significant stenosis.

Considering these findings, we exchanged the wire to 300 cm bare wire,
placed NAV6 Emboshield filter to the most distal popliteal artery, and
repeatedly performed thrombectomy of the entire right superficial femoral
artery and popliteal artery, and then predilatation with 5 x 100 mm
balloon, inflated up to 8 atmospheres for 40 seconds sequentially from
popliteal into the SFA. We repeated ultrasound, and considering severe
obstructive disease of the most distal popliteal artery, and restenosis at
the tip of the stent, stenting was commenced. Considering small size of
the most distal popliteal artery and presence of collaterals which we did
not want to cover, we used off label 4 x 38 mm Promus drug-eluting stent
exactly from bifurcation with tibioperoneal trunk and to the mid
popliteal artery. Then 5 x 50 mm covered Viabahn stent was placed to mid
popliteal artery overlapping with the old stent and post dilatation
performed with 5 x 40 mm balloon, inflated up to 12 atmospheres for 20
seconds twice, achieving good result.

Once we finished the mid distal popliteal angioplasty and stent, we again
performed ultrasound of the distal mid SFA, which showed complete
resolution of occlusion with thrombectomy and angioplasty; however, there
was significant residual stenosis, and some thrombotic material in the
proximal right SFA, so I placed a 6 x 100 mm Viabahn stent to the proximal
SFA, and then 7 x 60 mm Innova stent to the ostial proximal SFA
overlapping. The post dilatation was performed with 6 x 40 mm balloon,
inflated up to 8 atmospheres for 30 seconds sequentially in entire
proximal ostial SFA. The final angiogram of the SFA and popliteal artery
showed excellent procedural result, full stent expansion and apposition,
no residual thrombotic material, excellent brisk flow. The deep femoral
artery was not affected. We had an excellent brisk flow to the right
anterior tibial artery; however, there was evidence of thrombotic material
and spasm in the right peroneal artery, especially in the area of previous
60-70 percent mid portion stenosis.

Thrombectomy, and PTA of the right peroneal artery: I re-crossed peroneal
artery with a 300 cm Grand Slam wire after removing the filter, and we
performed first thrombectomy with a CAT6 Penumbra device successfully, and
then performed angioplasty with 2.5 x 120 mm balloon, inflated from mid
into the proximal right peroneal artery up to 4 atmospheres for 3 minutes,
balloon was then withdrawn, final angiogram obtained and showed excellent
procedural result, full resolution of occlusion and clot with excellent
brisk flow to the tibioperoneal trunk, peroneal artery, anterior tibial
artery. The patient tolerated the procedure well.

CONCLUSIONS:

1. Severe peripheral vascular disease with right leg critical limb
ischemia.
2. Occlusion of right superficial femoral artery and popliteal artery
inside previous stent, and near occlusion of the right distal
popliteal artery beyond the stent.
3. Successful angioplasty, mechanical thrombectomy, intravascular
ultrasound of the right proximal superficial femoral artery with a 6
x 100 Viabahn stent overlapped with 7 x 60 Eluvia drug-eluting
stent.
4. Successful thrombectomy, angioplasty and 4 x 38 mm Promus DES to the
most distal right popliteal artery overlapped with 5 x 50 mm Viabahn
covered stent.
5. Thrombotic occlusion of the right tibioperoneal trunk and peroneal
artery, successful mechanical thrombectomy, and angioplasty with 2.5
x 120 mm balloon of the right peroneal artery.
6. Patient to continue on dual antiplatelet therapy with aspirin and
Plavix, she will have post-procedural ultrasound within 1-2 weeks.
 
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