bhargavi
Guru
Indications
PVD (peripheral vascular disease) [I73.9 (ICD-10-CM)]
Peripheral venous insufficiency [I87.2 (ICD-10-CM)]
Left leg pain [M79.605 (ICD-10-CM)]
Conclusion
After obtaining informed consent, the patient was prepped and draped in the usual fashion. Approximately 10 mL 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 via the right femoral artery. We then obtained a 5 French contra catheter which was positioned into the distal abdominal aorta above the bifurcation. We then performed digital subtraction angiography of the distal abdominal aorta with bilateral iliofemoral runoff. This revealed patent bilateral common, internal, and external iliac vessels. On the right, common iliac vessel had a tubular distal stenosis of 40%. On the left, there was ostial 20-30% disease in the common iliac artery. The external iliac artery on the right was patent with mild luminal irregularities. The internal iliac vessel was also patent but appear to be small and underfilled. On the left, the external iliac was patent to the level of the common femoral artery. It had ostial 30% disease. The internal iliac artery was also patent but had a hazy ostial stenosis of 50% with TIMI-3 flow. Both common femoral vessels were patent.
*
We then obtained a 180 cm 0.035 inch stiff angled zip wire which was utilized to advance the contra catheter into the distal common femoral vessel on the left. We then performed selective digital subtraction angiography of the left lower extremity. This again revealed a widely patent common femoral vessel. The profunda femoris vessel was large and widely patent throughout its entire length. The superficial femoral artery was patent proximally but appear to be diffusely and moderately to severely diseased in its proximal segment with early mid occlusion and bridging collaterals into the distal vessel which reconstituted prior to the adductor canal. Beyond this, the vessel was patent. The popliteal artery was also patent above and below the knee. Just above the knee joint, there was a tubular stenosis of 30-40% in the popliteal. The below the knee popliteal was widely patent, and there was three-vessel runoff below the knee on the left.
*
After identification of severe disease involving the left superficial femoral artery we decided to proceed with intervention. We felt that there might be a channel through the area of occlusion that might allow for easy advancement of a wire and utilization of atherectomy. We therefore exchanged the contra catheter over a short Magic torque wire for a 7 French by 45 cm destination sheath. Heparin at a dose of 4000 units was administered in order to achieve an activated clotting time in excess of 200 seconds. At the end of the procedure, a 600 mg oral Plavix load was administered. We then withdrew the Magic torque wire and obtained a 300 cm length 0.014 inch Thruway wire which was advanced into the superficial femoral artery. Unfortunately, no child could be found, and because we were concerned about the possibility of extraluminal cannulization of the wire, we elected to abort attempts at further wiring with the Thruway and atherectomy. The Thruway wire was removed, and we obtained a long 260 cm length 0.035 inch stiff angled zip wire which, with assistance from a 5.0 x 100 cm stiff angle tip glide catheter, was advanced through the area of occlusion and into the distal superficial femoral artery. We then advanced the glide catheter into the true lumen beyond the area of occlusion and exchanged zip wire for a long Magic torque wire. Following this, we performed predilatation of the SFA utilizing a 5.0 x 150 mm Mustang balloon up to 10 atm of pressure over 3 overlapping inflations. Follow-up angiography revealed resumption of TIMI grade III antegrade flow throughout the superficial femoral artery with an area of linear dissection throughout the vessel excluding the vessel origin. We then proceeded with stenting, placing, in tandem, from distal to proximal, a 6.0 x 150 followed by 6.0 x 150 Innova self-expanding nitinol stents. Follow-up angiography after stent deployment revealed a very good angiographic result with some diminished stent deployment throughout. We then performed postdilatation of the entire stented length utilizing the aforementioned 5.0 x 150 mm Mustang balloon to as high as 16 atm of pressure. Follow-up angiography after postdilatation revealed an excellent result with no significant residual stenosis and no evidence of proximal distal edge stent dissection, thrombosis, or spasm. There is TIMI grade III flow throughout the vessel, and the patient was free of symptoms. We then concluded the angioplasty procedure.
*
The Magic torque wire and sheath were withdrawn to the level of the distal external iliac artery on the right. We then performed runoff angiography of the right lower extremity. This revealed a patent common femoral, superficial femoral, and profunda femoris artery. In the distal superficial femoral artery just above the adductor canal there was a tubular 30% stenosis noted. Popliteal was patent throughout its entire course, but there was again a tubular stenosis of 30 to perhaps 40% just above the knee joint. Below the knee, there was three-vessel runoff, though the posterior tibial artery appeared diffusely and severely diseased.
*
Nonselective injection of the right iliofemoral system revealed an acceptable position of the arterial sheath in the distal right common femoral artery above the bifurcation. There is no significant disease of the site of sheath insertion. As such, and after documentation of an activated clotting time of 196 seconds, the destination sheath was exchanged for a short 7 French sheath, after which a 6 French minx was utilized for hemostasis.
*
The patient was then transferred to the recovery area in stable condition.
*
Impression:
*
1. Severely diseased and ultimately occluded left SFA status post successful recanalization, angioplasty, and self-expanding stenting.
2. Three-vessel runoff below the knee on the left.
3. Mild right-sided disease with three-vessel runoff below the knee on the right.
4. Status post minx placement.
*
Plan:
*
1. Aspirin for life.
2. Plavix indefinitely.
thanks in advance
should I bill 75630( the doctor didn't describe renals just iliacs) or 75716, 37226 lft?
*
PVD (peripheral vascular disease) [I73.9 (ICD-10-CM)]
Peripheral venous insufficiency [I87.2 (ICD-10-CM)]
Left leg pain [M79.605 (ICD-10-CM)]
Conclusion
After obtaining informed consent, the patient was prepped and draped in the usual fashion. Approximately 10 mL 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 via the right femoral artery. We then obtained a 5 French contra catheter which was positioned into the distal abdominal aorta above the bifurcation. We then performed digital subtraction angiography of the distal abdominal aorta with bilateral iliofemoral runoff. This revealed patent bilateral common, internal, and external iliac vessels. On the right, common iliac vessel had a tubular distal stenosis of 40%. On the left, there was ostial 20-30% disease in the common iliac artery. The external iliac artery on the right was patent with mild luminal irregularities. The internal iliac vessel was also patent but appear to be small and underfilled. On the left, the external iliac was patent to the level of the common femoral artery. It had ostial 30% disease. The internal iliac artery was also patent but had a hazy ostial stenosis of 50% with TIMI-3 flow. Both common femoral vessels were patent.
*
We then obtained a 180 cm 0.035 inch stiff angled zip wire which was utilized to advance the contra catheter into the distal common femoral vessel on the left. We then performed selective digital subtraction angiography of the left lower extremity. This again revealed a widely patent common femoral vessel. The profunda femoris vessel was large and widely patent throughout its entire length. The superficial femoral artery was patent proximally but appear to be diffusely and moderately to severely diseased in its proximal segment with early mid occlusion and bridging collaterals into the distal vessel which reconstituted prior to the adductor canal. Beyond this, the vessel was patent. The popliteal artery was also patent above and below the knee. Just above the knee joint, there was a tubular stenosis of 30-40% in the popliteal. The below the knee popliteal was widely patent, and there was three-vessel runoff below the knee on the left.
*
After identification of severe disease involving the left superficial femoral artery we decided to proceed with intervention. We felt that there might be a channel through the area of occlusion that might allow for easy advancement of a wire and utilization of atherectomy. We therefore exchanged the contra catheter over a short Magic torque wire for a 7 French by 45 cm destination sheath. Heparin at a dose of 4000 units was administered in order to achieve an activated clotting time in excess of 200 seconds. At the end of the procedure, a 600 mg oral Plavix load was administered. We then withdrew the Magic torque wire and obtained a 300 cm length 0.014 inch Thruway wire which was advanced into the superficial femoral artery. Unfortunately, no child could be found, and because we were concerned about the possibility of extraluminal cannulization of the wire, we elected to abort attempts at further wiring with the Thruway and atherectomy. The Thruway wire was removed, and we obtained a long 260 cm length 0.035 inch stiff angled zip wire which, with assistance from a 5.0 x 100 cm stiff angle tip glide catheter, was advanced through the area of occlusion and into the distal superficial femoral artery. We then advanced the glide catheter into the true lumen beyond the area of occlusion and exchanged zip wire for a long Magic torque wire. Following this, we performed predilatation of the SFA utilizing a 5.0 x 150 mm Mustang balloon up to 10 atm of pressure over 3 overlapping inflations. Follow-up angiography revealed resumption of TIMI grade III antegrade flow throughout the superficial femoral artery with an area of linear dissection throughout the vessel excluding the vessel origin. We then proceeded with stenting, placing, in tandem, from distal to proximal, a 6.0 x 150 followed by 6.0 x 150 Innova self-expanding nitinol stents. Follow-up angiography after stent deployment revealed a very good angiographic result with some diminished stent deployment throughout. We then performed postdilatation of the entire stented length utilizing the aforementioned 5.0 x 150 mm Mustang balloon to as high as 16 atm of pressure. Follow-up angiography after postdilatation revealed an excellent result with no significant residual stenosis and no evidence of proximal distal edge stent dissection, thrombosis, or spasm. There is TIMI grade III flow throughout the vessel, and the patient was free of symptoms. We then concluded the angioplasty procedure.
*
The Magic torque wire and sheath were withdrawn to the level of the distal external iliac artery on the right. We then performed runoff angiography of the right lower extremity. This revealed a patent common femoral, superficial femoral, and profunda femoris artery. In the distal superficial femoral artery just above the adductor canal there was a tubular 30% stenosis noted. Popliteal was patent throughout its entire course, but there was again a tubular stenosis of 30 to perhaps 40% just above the knee joint. Below the knee, there was three-vessel runoff, though the posterior tibial artery appeared diffusely and severely diseased.
*
Nonselective injection of the right iliofemoral system revealed an acceptable position of the arterial sheath in the distal right common femoral artery above the bifurcation. There is no significant disease of the site of sheath insertion. As such, and after documentation of an activated clotting time of 196 seconds, the destination sheath was exchanged for a short 7 French sheath, after which a 6 French minx was utilized for hemostasis.
*
The patient was then transferred to the recovery area in stable condition.
*
Impression:
*
1. Severely diseased and ultimately occluded left SFA status post successful recanalization, angioplasty, and self-expanding stenting.
2. Three-vessel runoff below the knee on the left.
3. Mild right-sided disease with three-vessel runoff below the knee on the right.
4. Status post minx placement.
*
Plan:
*
1. Aspirin for life.
2. Plavix indefinitely.
thanks in advance
should I bill 75630( the doctor didn't describe renals just iliacs) or 75716, 37226 lft?
*