After obtaining informed consent, the patient was prepped and draped surgically. Bilateral femoral artery cutdowns were performed by Dr. Daniel Marelli for the purposes of endovascular repair of a supra and infrarenal abdominal aortic aneurysm. For details of the EVAR procedure, please see Dr. Marelli's note. After completion of placement of the infrarenal piece of the endograft as well as the iliac limbs, myself and Dr. Singh were called upon to perform bilateral renal artery intervention with placement of periscope stents. Through a 22 French catheter placed in the right femoral artery, we advanced a total of 2 7 French standard length IMA guide catheters. These guide catheters were selectively engaged into the right and left renal arteries. Selective injections simultaneously of the bilateral renal arteries revealed a severe, ulcerated 80 to 85% stenosis on the right, with a tubular 30% stenosis on the left. Given the presence of disease in both the renal arteries, we elected to perform angioplasty of both of these vessels to allow for adequate passage of larger diameter wires and destination sheaths for the purposes of placement of Viabahn stents. We obtained a total of two 180 cm 0.014 inch Asahi pro-water wires, advancing 1 wire into the mid to distal portion of the right renal artery and the second wire into the left renal artery. We then performed predilatation of the left renal artery utilizing a 6.0 x 20 mm Sterling balloon up to 14 atm of pressure. The left renal artery balloon and stent were placed by Dr. S, with the right renal artery balloon and stent performed by myself. We then performed predilatation of the right renal artery first utilizing a 5.0 x 20 mm Sterling balloon up to 14 atm of pressure, followed by further predilatation with the aforementioned 6 mm Sterling balloon. Follow-up angiography revealed an improvement in the appearance of both renal arteries. At this time, we felt that it would be reasonable to exchange wires. We turned our attention first to the right renal artery,, advancing a 0.018 inch x 300 cm Thruway wire successfully into the proximal right renal artery subbranch. After this, the Asahi pro-water wire was withdrawn. We then attempted to do the same on the left side, but because of difficulties with guide catheter positioning, this was initially unsuccessful. Ultimately, we obtained a 4 French by 120 cm stiff angled tip glide catheter that was advanced over a 0.014 inch x 300 cm Savion wire into a renal artery subbranch. This wire was then withdrawn, and we were able to successfully advance a second 0.018 inch x 300 cm Thruway wire into the distal most portion of the left renal artery. After this, the 7 French IMA guide catheters were withdrawn and exchanged for a 7 French by 90 cm destination sheath which was positioned in each of the mid portion of the renal arteries. Following this, we obtained a total of 2 Gore 8.0 x 100 mm Viabahn self-expanding covered stents which were each in turn deployed via the destination sheath from the midportion of each renal artery backward into the descending abdominal aorta. We then performed simultaneous balloon inflation of both of these stents utilizing a total of two 7 x 100 mm Sterling balloons deployed up to 10 atm of pressure. At the request of the vascular surgical team, these balloons were left inflated while the final piece of the stent graft was deployed ideally from just below the ostium of the superior mesenteric artery into the infrarenal abdominal aorta. Following deployment of this piece of the graft, final molding balloon inflation over the graft was performed while the renal artery balloons remained simultaneously inflated. After completion of this part of the procedure, both Sterling balloons in the renal artery stents were deflated and withdrawn. Abdominal aortography performed following this portion of the procedure revealed upward migration of the stent graft such that the fabric was covering the ostium of the superior mesenteric artery. There was subsequently diminished flow in the SMA. Additionally, there was only minimal protrusion of the Viabahn stents from the renal arteries beyond the final piece of stent graft in the aorta. Because of concerns about the ability to protect and maintain renal perfusion, it was decided to perform additional stenting to extend the area covered by the Viabahn stents. We therefore obtained a total of two 8 x 27 mm express LD balloon expandable stents for extension. I turned my attention first to the left renal artery stent, and the express LD stent was successfully deployed to 15 atm of pressure. Follow-up visualization revealed no evidence of migration of any of the stented segments. I attempted to do the same with the right-sided stent, but the express LD stent deployment system became partially snagged into the distal aspect of the Viabahn stent, resulting in its migration upward behind the final endograft. We removed the express LD stent deployment system and obtained a 7.0 x 40 mm Sterling balloon. We were able to successfully advance this into the Viabahn stent, and inflated the balloon to maximum pressures. While the balloon was inflated, we gently pulled the balloon downward and were able to extend the stent back across the distal portion of the aortic endograft. After deflation of the balloon, we were able to advance the destination sheath successfully into the stent, which allowed for much easier positioning and successful placement of the second 8.0 x 27 mm express LD stent, which was also deployed to 15 atm of pressure. Satisfied with this result, we concluded this portion of the procedure. We withdrew the wires from the renal arteries along with both destination sheath.
We then began to turn our attention to the superior mesenteric artery. We first attempted to access the SMA retrogradely from the abdominal aorta through an 18 French sheath in the left femoral artery. However, due to concerns by Dr. Marelli about ischemia to the lower extremities, we aborted this part of the procedure so that Dr. Marelli and his assistant could remove the arterial sheaths in the bilateral femoral arteries and affect surgical closure of these areas. Following surgical closure, we turned our attention back to recanalizing the SMA. This will be dictated in a separate note.
1. Successful bilateral renal artery balloon angioplasty and placement of covered stents, with additional balloon expandable stenting distally to allow for successful retrograde perfusion of the renal arteries.
2. Successful endovascular stenting complicated by migration of most proximal endograft with coverage of ostial SMA.
1. Left brachial access for attempted intervention of SM
should I just do 37236, for one physician and 37237 - xp for second physician ?
I am coding for hospital
thanks in advance