bhargavi
Guru
Conclusion
After obtaining informed consent, the patient was prepped and draped in the usual fashion. Approximately 10 mL's 2% lidocaine anesthesia was administered to the right groin prior to placement of the arterial sheath. Under fluoroscopic guidance and using modified Seldinger technique, a 5 French arterial sheath was placed without difficulty into the right femoral artery. We then obtained a 5 French contra catheter which was positioned in the distal abdominal aorta. We performed digital subtraction angiography of the distal abdominal aorta with bilateral iliofemoral runoff. This revealed patent bilateral common and external iliac vessels. The right internal iliac vessel was subtotally occluded. The left internal iliac vessel was widely patent. The external iliacs were patent to the level of the common femorals bilaterally. There are minor luminal irregularities in both external iliac vessels.
*
Next, with the assistance of 180 cm 0.035 inch stiff angle tip zip wire, we advance the contra catheter into the distal external iliac artery on the left and performed selective digital subtraction angiography of the left lower extremity. This revealed a lengthy area of 50-70% disease throughout the proximal mid and distal SFA with occlusion of the distal SFA just above the adductor canal and reconstitution at the end of the adductor canal. The popliteal artery was patent throughout its entire course, and there was three-vessel runoff below the knee on the left.
*
After identification of disease of the left SFA, we proceeded with percutaneous revascularization. Heparin at a dose of 3000 units by intravenous bolus was administered in order to achieve an activated clotting time in excess of 200 seconds. Later on in the procedure, an additional 1000 unit heparin bolus was administered. At the end of the procedure, a 600 mg oral Plavix load was administered. The contra catheter and 5 French sheath were exchanged over a 180 cm Magic torque wire for a 6 x 45 cm destination sheath. We then obtained a 260 cm length stiff angled zip wire and 4 French by 100 cm angle-tip glide catheter to utilize for passage of the wire into and beyond the point of occlusion. This was initially unsuccessful, and we made additional attempts utilizing first a 300 cm 0.014 inch journey wire, followed by a 300 cm 0.014 inch 18 g tip victory wire. Both of these were also unsuccessful. We then reobtained zip wire and, with mild difficulty, were able to advance through the occlusion and into the true lumen beyond. We then performed predilatation of the area of occlusion utilizing a 5.0 x 100 mm Mustang balloon deployed up to 14 atm of pressure. We performed additional balloon dilatation to the ostium of the SFA utilizing the same balloon. Follow-up angiography revealed resumption of TIMI grade III flow throughout the vessel with a nonocclusive thrombus at the site of initial balloon angioplasty. We performed additional balloon angioplasty at that site utilizing a 5.0 x 40 mm Mustang balloon and drew an ACT. The ACT was 184 seconds, so an additional 1000 units of heparin was administered as above. We then performed drug-coated balloon angioplasty of the length of disease in the SFA utilizing, in tandem, a 5.0 x 150 and 5.0 x 150 mm Lutonix drug-coated balloon. Follow-up angiography after drug-eluting balloon deployment revealed an excellent result in the ostial to mid SFA with an overall improvement but still persistent dissection at the site of recanalization of the vessel. We elected then to proceed with stenting of the recanalized segment. We obtained, advanced, and deployed a 6.0 x 150 mm Innova self-expanding nitinol stent. The stented segment was then postdilated once again utilizing the aforementioned 5.0 x 150 mm Mustang balloon up to 16 atm of pressure. Follow-up angiography revealed an excellent result within the SFA and within the stented segment with some sluggish flow at the level of the mid popliteal just above the knee. We then visualized another small nonocclusive thrombus. We performed additional balloon dilatation at that site utilizing the aforementioned 5.0 x 40 mm Mustang balloon up to 10 atm of pressure over 2 overlapping inflations. Follow-up angiography revealed resolution of the area of thrombus with brisk TIMI grade III flow to the foot bilaterally and no evidence of vascular cut off. Satisfied with this result, we completed the angioplasty procedure. The procedural wire was withdrawn to the level of the external iliac, and the destination sheath was then withdrawn to the level of the right external iliac.
*
We then performed digital subtraction angiography of the right lower extremity which revealed widely patent common, superficial, and profunda femoris arteries. The popliteal artery was also widely patent. There was three-vessel runoff to the foot on the right through a nondiseased anterior tibial vessel and a moderately to severely diseased tibioperoneal trunk.
*
Nonselective injection of the right iliofemoral system revealed acceptable sheath positioning in the distal right common femoral artery above the bifurcation. There was no angiographic evidence of disease at the site of sheath insertion. As such, and after documentation of an ending activated clotting time of 200 seconds, a 6 French minx was deployed for hemostasis.
*
The patient was then transferred to the recovery area in stable condition.
*
Impression:
*
1. Diffuse moderate to severe SFA disease culminating in a lengthy occlusion prior to the adductor canal status post recanalization, standard balloon and drug-coated balloon angioplasty, and stenting.
2. Three-vessel runoff below the knee on the left.
3. Mild luminal irregularities of iliofemoral system on the right with three-vessel runoff below the knee through a diseased tibioperoneal trunk.
4. Status post minx placement.
*
Plan:
*
1. Aspirin for life.
2. Plavix indefinitely.
3. Aggressive risk factor modification.
thanks in advance
I am thinking 75716-xu, 37226-lft, 36247- is cath placement included in 37226?
I am coding for facility
*
After obtaining informed consent, the patient was prepped and draped in the usual fashion. Approximately 10 mL's 2% lidocaine anesthesia was administered to the right groin prior to placement of the arterial sheath. Under fluoroscopic guidance and using modified Seldinger technique, a 5 French arterial sheath was placed without difficulty into the right femoral artery. We then obtained a 5 French contra catheter which was positioned in the distal abdominal aorta. We performed digital subtraction angiography of the distal abdominal aorta with bilateral iliofemoral runoff. This revealed patent bilateral common and external iliac vessels. The right internal iliac vessel was subtotally occluded. The left internal iliac vessel was widely patent. The external iliacs were patent to the level of the common femorals bilaterally. There are minor luminal irregularities in both external iliac vessels.
*
Next, with the assistance of 180 cm 0.035 inch stiff angle tip zip wire, we advance the contra catheter into the distal external iliac artery on the left and performed selective digital subtraction angiography of the left lower extremity. This revealed a lengthy area of 50-70% disease throughout the proximal mid and distal SFA with occlusion of the distal SFA just above the adductor canal and reconstitution at the end of the adductor canal. The popliteal artery was patent throughout its entire course, and there was three-vessel runoff below the knee on the left.
*
After identification of disease of the left SFA, we proceeded with percutaneous revascularization. Heparin at a dose of 3000 units by intravenous bolus was administered in order to achieve an activated clotting time in excess of 200 seconds. Later on in the procedure, an additional 1000 unit heparin bolus was administered. At the end of the procedure, a 600 mg oral Plavix load was administered. The contra catheter and 5 French sheath were exchanged over a 180 cm Magic torque wire for a 6 x 45 cm destination sheath. We then obtained a 260 cm length stiff angled zip wire and 4 French by 100 cm angle-tip glide catheter to utilize for passage of the wire into and beyond the point of occlusion. This was initially unsuccessful, and we made additional attempts utilizing first a 300 cm 0.014 inch journey wire, followed by a 300 cm 0.014 inch 18 g tip victory wire. Both of these were also unsuccessful. We then reobtained zip wire and, with mild difficulty, were able to advance through the occlusion and into the true lumen beyond. We then performed predilatation of the area of occlusion utilizing a 5.0 x 100 mm Mustang balloon deployed up to 14 atm of pressure. We performed additional balloon dilatation to the ostium of the SFA utilizing the same balloon. Follow-up angiography revealed resumption of TIMI grade III flow throughout the vessel with a nonocclusive thrombus at the site of initial balloon angioplasty. We performed additional balloon angioplasty at that site utilizing a 5.0 x 40 mm Mustang balloon and drew an ACT. The ACT was 184 seconds, so an additional 1000 units of heparin was administered as above. We then performed drug-coated balloon angioplasty of the length of disease in the SFA utilizing, in tandem, a 5.0 x 150 and 5.0 x 150 mm Lutonix drug-coated balloon. Follow-up angiography after drug-eluting balloon deployment revealed an excellent result in the ostial to mid SFA with an overall improvement but still persistent dissection at the site of recanalization of the vessel. We elected then to proceed with stenting of the recanalized segment. We obtained, advanced, and deployed a 6.0 x 150 mm Innova self-expanding nitinol stent. The stented segment was then postdilated once again utilizing the aforementioned 5.0 x 150 mm Mustang balloon up to 16 atm of pressure. Follow-up angiography revealed an excellent result within the SFA and within the stented segment with some sluggish flow at the level of the mid popliteal just above the knee. We then visualized another small nonocclusive thrombus. We performed additional balloon dilatation at that site utilizing the aforementioned 5.0 x 40 mm Mustang balloon up to 10 atm of pressure over 2 overlapping inflations. Follow-up angiography revealed resolution of the area of thrombus with brisk TIMI grade III flow to the foot bilaterally and no evidence of vascular cut off. Satisfied with this result, we completed the angioplasty procedure. The procedural wire was withdrawn to the level of the external iliac, and the destination sheath was then withdrawn to the level of the right external iliac.
*
We then performed digital subtraction angiography of the right lower extremity which revealed widely patent common, superficial, and profunda femoris arteries. The popliteal artery was also widely patent. There was three-vessel runoff to the foot on the right through a nondiseased anterior tibial vessel and a moderately to severely diseased tibioperoneal trunk.
*
Nonselective injection of the right iliofemoral system revealed acceptable sheath positioning in the distal right common femoral artery above the bifurcation. There was no angiographic evidence of disease at the site of sheath insertion. As such, and after documentation of an ending activated clotting time of 200 seconds, a 6 French minx was deployed for hemostasis.
*
The patient was then transferred to the recovery area in stable condition.
*
Impression:
*
1. Diffuse moderate to severe SFA disease culminating in a lengthy occlusion prior to the adductor canal status post recanalization, standard balloon and drug-coated balloon angioplasty, and stenting.
2. Three-vessel runoff below the knee on the left.
3. Mild luminal irregularities of iliofemoral system on the right with three-vessel runoff below the knee through a diseased tibioperoneal trunk.
4. Status post minx placement.
*
Plan:
*
1. Aspirin for life.
2. Plavix indefinitely.
3. Aggressive risk factor modification.
thanks in advance
I am thinking 75716-xu, 37226-lft, 36247- is cath placement included in 37226?
I am coding for facility
*