Wiki need help with peripheral angio/iliac stent

bhargavi

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Conclusion



After obtaining informed consent, the patient was prepped and draped in the usual fashion.  Approximately 5 mL 2% lidocaine anesthesia was administered to the left antebrachial fossa prior to placement of the arterial sheath.  Under fluoroscopic guidance and using modified Seldinger technique, a 6 French sheath was placed via micropuncture technique into the left brachial artery.  Heparin 2000 units was administered into the sheath in order to prevent thrombus formation.  We then obtained a 6 French JR4 catheter which was advanced over standard procedural wire into the distal abdominal aorta just above the aortoiliac bifurcation.  Following this, we performed digital subtraction angiography of the distal abdominal aorta with bilateral iliofemoral runoff.  This revealed on the left a patent common iliac vessel with an area of calcified moderate disease distally.  The external and internal iliac vessels were patent to the level of the common femoral artery.  On the left, there was a heavily calcified 90 to 95% eccentric stenosis in the ostium of the common iliac vessel.  Both the internal and external iliac vessels were patent, but there was calcified 70% disease in the common femoral on the right.

After identification of disease in the common iliac and common femoral on the right, we elected to proceed with percutaneous intervention.  We initially obtained a long Magic torque wire which was advanced into the left common iliac vessel.  We withdrew the JR4 catheter and a short 6 French sheath, exchanging it for a 6 x 90 cm destination sheath.  We then obtained a 5 French by 100 cm angled tip glide catheter in the hopes of being able to successfully navigate a wire across the iliac stenosis.  We first attempted to utilize a zip wire, but were unsuccessful in advancing this wire beyond the most proximal portion of the iliac.  We then obtained a 300 cm length V 18 control wire but were again unsuccessful in advancing this wire to the intended destination.  Finally, we obtained a 300 cm length pilot 200 wire.  Initially, we were unsuccessful with advancing this wire.  We then decided to utilize a different catheter as a back-up catheter.  We removed the 5 French glide catheter and obtained a 6 French Bern catheter, which allowed for acceptable back-up and successful advancement of the pilot 200 wire beyond both the iliac and common femoral stenoses and into the SFA.  After advancement of this wire, we removed the Bern catheter and obtained 0.018 inch Rubicon catheter.  This was advanced over the 014 wire into the proximal superficial femoral artery.  We then removed the pilot 200 wire, and readvanced the aforementioned V 18 wire.  We then performed balloon angioplasty of both the common femoral and common iliac stenoses utilizing a 4.0 x 80 mm Sterling balloon which was deployed to 14 atm of pressure.  Follow-up angiography revealed an improvement in the angiographic appearance of the vessel.  We decided at that point to perform additional balloon angioplasty, this time utilizing a 6.0 x 60 mm Sterling balloon again deployed to 14 atm of pressure over both the common femoral and common iliac stenoses.  Before doing so, however, we performed additional angiography of the right lower extremity runoff.  This revealed patency of the superficial femoral artery to the level of the adductor canal with mild calcification but no focal stenosis.  In the above-knee popliteal, there was a focal 95 to 99% stenosis with additional disease beyond the above the knee region.  Before performing balloon angioplasty with the 6.0 x 60 mm Sterling balloon, we attempted to advance this balloon as far distally as possible to determine whether or not we would be able to reach the above-knee popliteal stenoses from the left brachial approach.  Unfortunately, although the wire would reach to the area of interest, the balloon catheter would not.  Given that this was the longest balloon we had available, we knew that we would not be able to perform definitive intervention on the above-knee popliteal during this procedure.  We then went ahead and performed balloon angioplasty of the common femoral and common iliac vessel as above.  Follow-up angiography again revealed an improvement in the overall appearance of the vessel.  We then removed this balloon and obtained a 0.035 inch Rubicon catheter.  The Rubicon catheter was advanced into the superficial femoral artery.  The V 18 wire was removed and exchanged for a 260 cm length Magic torque wire for the remainder of the procedure.

We then obtained left common femoral access utilizing a 6 French by 24 cm sheath.  We did this for the purposes of performing simultaneous bilateral iliac stenting as the lesion in the right common iliac necessitated coverage into the distal abdominal aorta.  We then obtained a total of 2 stents.  These were balloon expandable express LD stents measuring 8 x 37 mm in size.  We performed simultaneous stenting of the bilateral common iliac stents to 14 atm of pressure.  Follow-up angiography revealed a marked improvement in the appearance of both common iliac vessels, with an area of geographic miss on the left side.  We performed postdilatation of both stents utilizing a total of two 9.0 x 20 mm Mustang balloons deployed up to 18 atm of pressure over multiple overlapping inflations.  Follow-up angiography revealed an excellent result bilaterally with no residual stenosis and no evidence of proximal or distal edge dissection, thrombosis, or spasm.  Satisfied with this result, we concluded this portion of the procedure.  In order to cover the remaining lesion on the left side, we obtained a second balloon expandable stent measuring 8.0 x 27 mm in diameter and deployed it in overlapping fashion up to 14 atm of pressure.  We then postdilated this stent utilizing the aforementioned 9.0 x 20 mm Mustang balloon.  Follow-up angiography revealed an excellent result on the left iliac system as well.

We then turned our attention to the right common femoral artery stenosis.  We decided at this point to perform drug-coated balloon angioplasty of this lesion.  We therefore obtained a 6.0 x 100 mm Lutonix drug-coated balloon and performed balloon angioplasty of this site for a total of 3 minutes at 12 atm of pressure.  Follow-up angiography after drug-eluting balloon treatment revealed a very nice angiographic result with no evidence of dissection, thrombosis, or spasm, and a marked improvement in the luminal diameter of the vessel.  Satisfied with this result, we concluded this portion of the procedure as well.

We then performed runoff angiography of the bilateral lower extremities.

Digital subtraction runoff angiography on the right revealed a patent superficial and profunda femoris artery with scattered calcification throughout but no significant stenosis.  In the above-knee popliteal just beyond the adductor canal, there was a 95% stenosis.  There was patchy calcified 70 to 80% disease beyond.  The popliteal behind the knee was widely patent, and there was calcified but three-vessel runoff below the knee on the right.

On the left, the common, superficial, and profunda femoris arteries were all patent.  There did appear to be a calcified mild stenosis at the ostium of the SFA.  The remainder of the SFA was widely patent, as was the popliteal vessel on the left with patchy 20 to 30% disease.  There was two-vessel runoff below the knee on the left side, with evidence of occlusion of the anterior tibial vessel in the proximal and early middle segment.

At the end of the procedure, the activated clotting time was 247 seconds, so we elected to secure both sheaths in place and recheck an activated clotting time after 30 minutes with plans to remove the arterial sheaths if the ACT was less than 200 seconds.

The patient was under general anesthesia during the entire procedure.  Of note, shortly after induction, the patient developed severe hypotension which required initiation of a phenylephrine infusion and multiple doses of vasopressin to maintain pressures throughout the procedure.  This hypotension was present prior to obtaining any sort of arterial access.  An arterial blood gas performed during the procedure revealed normal pH, PCO2, and PO2 levels.

Impression:

1.  Critical ostial right common iliac stenosis with moderate left common iliac disease status post successful simultaneous kissing stenting of the bilateral common iliacs, with additional stenting of the left common iliac.
2.  Severe disease of right common femoral artery, status post successful standard and drug-eluting balloon angioplasty.
3.  Severe above-the-knee popliteal disease on the right, not reachable via brachial access.
4.  Three-vessel runoff below the knee on the right.
5.  Mild to moderate SFA disease on the left.
6.  Two-vessel runoff below the knee on the left.
7.  Manual compression to be utilized for hemostasis of both femoral and brachial access, with placement of a FemoStop device on the left at the time of sheath removal.

thanks in advance

should I do 75716-xu, 37221-50, 37223-LT, 37224-RT?

I bill for hospital























 













 
I got 75716-XU, 37224-RT and 37221-50. The additional stenting of the left common iliac would be included in the kissing stent.
 
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