bhargavi
Guru
Conclusion
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 into the distal abdominal aorta above the aortic bifurcation. We then performed a digital subtraction angiography of the distal abdominal aorta with bilateral iliofemoral runoff. There was an old dissection in the distal abdominal aorta with no translesional pressure gradient noted. The abdominal aorta itself was patent with minimal disease. On the right, the common, external, and internal iliac vessels were all patent. There was patchy 30% disease in the external iliac vessel. On the left, the common iliac vessel appeared to be somewhat aneurysmal relative to the right. The internal iliac vessel was patent with sluggish filling. The external iliac vessel had a lengthy area of 30% disease followed by an area of stenosis which was difficult to quantify within a band just above the common femoral vessel. On some views, this area appeared to be as severe as 50% narrowed.
*
We then obtained a 180 cm stiff angled tip zip wire which was advanced into the proximal profunda femoris artery on the left. We then advanced the contra catheter into the proximal common femoral vessel beyond the area of concern. Following this, we performed a digital subtraction runoff angiography of the left lower extremity through the contra catheter. This revealed a lengthy area of subtotal occlusion of the SFA throughout its proximal and mid segments with full reconstitution of the distal superficial femoral artery at the entrance to the adductor canal via collaterals from the profunda femoris. The popliteal artery was patent throughout its proximal, middle, and distal segments. There was three-vessel runoff via undiseased vessels on the left.
*
To determine the hemodynamic significance of the area of concern in the distal external iliac, we withdrew the contra catheter and found a less than 10 mm translesional gradient noted.
*
After identification of a lengthy area of severe disease in the left superficial femoral artery, we elected to proceed with percutaneous intervention. The contra catheter was withdrawn over the aforementioned zip wire. We then withdrew the 5 French arterial sheath and placed a 6 x 45 cm destination sheath in the distal external iliac artery on the left. Heparin at a dose of 4000 units by intravenous bolus was administered for anticoagulant effect. No aspirin or Plavix was given at the end of the procedure as the patient was already on chronic aspirin and Plavix therapy. We then obtained a short 4 French straight glide catheter which we used to guide the zip wire into the superficial femoral artery. The zip wire was then removed and we attempted to advance a long Magic torque wire into the distal vessel but were met with significant resistance. For this reason, we withdrew this wire and obtain a long 300 cm 0.035 inch stiff angled tip zip wire which was successfully advanced into the distal superficial femoral and proximal popliteal artery. We then obtained 5.0 x 150 mm mustang balloon which we attempted to advance through the subtotal occlusion in the SFA for balloon angioplasty. Unfortunately, we were again met with much resistance, so we withdrew this balloon. We obtained a 4 French by 100 cm straight tipped glide catheter which was advanced into the proximal popliteal vessel. We then exchanged the long zip wire for a 300 cm V 18 wire and then removed the glide catheter. We then obtained a 5.0 x 220 mm Sterling balloon which was advanced into the area of concern. We then performed 2 overlapping inflations of the superficial femoral artery utilizing this balloon deployed up to 12 atm of pressure. Follow-up angiography revealed resumption of TIMI grade 3 antegrade flow throughout the superficial femoral artery with multiple areas of short dissection within the vessel. We then proceeded with stenting, placing, in tandem from distal to proximal, a 6.0 x 150, 6.0 x 100, and 6.0 x 40 mm Innova self-expanding stents extending from the ostium of the SFA into the distal SFA. Follow-up angiography revealed further improvement in the angiographic appearance of the vessel with some diminished stent deployment throughout. We then performed postdilatation of the entire stent length utilizing the aforementioned 5.0 x 150 mm mustang balloon up to 22 atm of pressure over multiple overlapping inflations. Follow-up angiography revealed an excellent angiographic result with no significant residual stenosis and no evidence of proximal or distal edge dissection, thrombosis, or spasm. There was brisk TIMI grade 3 flow into the runoff vessels on the right, and the patient was free of symptoms. We therefore elected to conclude this portion of the procedure. The V 18 wire was withdrawn and the destination sheath was withdrawn to the level of the external iliac artery on the right. We then performed runoff angiography of the right lower extremity. This revealed a patent proximal superficial femoral artery in the mid vessel there was a lengthy area of severe disease extending into the proximal above-the-knee popliteal. The remainder of the popliteal artery was free of significant disease aside from a 30% stenosis at the knee. There was three-vessel runoff below the knee on the right.
*
Nonselective injection of the right iliofemoral system revealed acceptable positioning of the arterial sheath in the distal right common femoral artery above the bifurcation. As there was no disease of the site of sheath insertion, the 6 French destination sheath was exchanged for a 6 French short sheath, after which a 6 French minx device was deployed for hemostasis after confirming an activated clotting time of 168 seconds.
*
The patient was then transferred to the recovery area in stable condition.
*
Impression:
*
1. Lengthy subtotal occlusion of left SFA status post successful recanalization, angioplasty, and self-expanding stenting.
2. Three-vessel runoff below the knee on the left.
3. Moderate but nonhemodynamically significant distal left external iliac stenosis.
4. Mild right external iliac disease.
5. Severe mid to distal SFA stenosis on the right with three-vessel runoff below the knee.
6. Status post minx placement.
*
Plan:
*
1. Aspirin for life.
2. Plavix indefinitely.
3. Return in 2 weeks for left femoral access and crossover for right SFA intervention.
*I have coded 75630-xu,37226-lft,36247
please let me know if this correct or should I do 75716,37226,36247 instead?
thanks in advance
*
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 into the distal abdominal aorta above the aortic bifurcation. We then performed a digital subtraction angiography of the distal abdominal aorta with bilateral iliofemoral runoff. There was an old dissection in the distal abdominal aorta with no translesional pressure gradient noted. The abdominal aorta itself was patent with minimal disease. On the right, the common, external, and internal iliac vessels were all patent. There was patchy 30% disease in the external iliac vessel. On the left, the common iliac vessel appeared to be somewhat aneurysmal relative to the right. The internal iliac vessel was patent with sluggish filling. The external iliac vessel had a lengthy area of 30% disease followed by an area of stenosis which was difficult to quantify within a band just above the common femoral vessel. On some views, this area appeared to be as severe as 50% narrowed.
*
We then obtained a 180 cm stiff angled tip zip wire which was advanced into the proximal profunda femoris artery on the left. We then advanced the contra catheter into the proximal common femoral vessel beyond the area of concern. Following this, we performed a digital subtraction runoff angiography of the left lower extremity through the contra catheter. This revealed a lengthy area of subtotal occlusion of the SFA throughout its proximal and mid segments with full reconstitution of the distal superficial femoral artery at the entrance to the adductor canal via collaterals from the profunda femoris. The popliteal artery was patent throughout its proximal, middle, and distal segments. There was three-vessel runoff via undiseased vessels on the left.
*
To determine the hemodynamic significance of the area of concern in the distal external iliac, we withdrew the contra catheter and found a less than 10 mm translesional gradient noted.
*
After identification of a lengthy area of severe disease in the left superficial femoral artery, we elected to proceed with percutaneous intervention. The contra catheter was withdrawn over the aforementioned zip wire. We then withdrew the 5 French arterial sheath and placed a 6 x 45 cm destination sheath in the distal external iliac artery on the left. Heparin at a dose of 4000 units by intravenous bolus was administered for anticoagulant effect. No aspirin or Plavix was given at the end of the procedure as the patient was already on chronic aspirin and Plavix therapy. We then obtained a short 4 French straight glide catheter which we used to guide the zip wire into the superficial femoral artery. The zip wire was then removed and we attempted to advance a long Magic torque wire into the distal vessel but were met with significant resistance. For this reason, we withdrew this wire and obtain a long 300 cm 0.035 inch stiff angled tip zip wire which was successfully advanced into the distal superficial femoral and proximal popliteal artery. We then obtained 5.0 x 150 mm mustang balloon which we attempted to advance through the subtotal occlusion in the SFA for balloon angioplasty. Unfortunately, we were again met with much resistance, so we withdrew this balloon. We obtained a 4 French by 100 cm straight tipped glide catheter which was advanced into the proximal popliteal vessel. We then exchanged the long zip wire for a 300 cm V 18 wire and then removed the glide catheter. We then obtained a 5.0 x 220 mm Sterling balloon which was advanced into the area of concern. We then performed 2 overlapping inflations of the superficial femoral artery utilizing this balloon deployed up to 12 atm of pressure. Follow-up angiography revealed resumption of TIMI grade 3 antegrade flow throughout the superficial femoral artery with multiple areas of short dissection within the vessel. We then proceeded with stenting, placing, in tandem from distal to proximal, a 6.0 x 150, 6.0 x 100, and 6.0 x 40 mm Innova self-expanding stents extending from the ostium of the SFA into the distal SFA. Follow-up angiography revealed further improvement in the angiographic appearance of the vessel with some diminished stent deployment throughout. We then performed postdilatation of the entire stent length utilizing the aforementioned 5.0 x 150 mm mustang balloon up to 22 atm of pressure over multiple overlapping inflations. Follow-up angiography revealed an excellent angiographic result with no significant residual stenosis and no evidence of proximal or distal edge dissection, thrombosis, or spasm. There was brisk TIMI grade 3 flow into the runoff vessels on the right, and the patient was free of symptoms. We therefore elected to conclude this portion of the procedure. The V 18 wire was withdrawn and the destination sheath was withdrawn to the level of the external iliac artery on the right. We then performed runoff angiography of the right lower extremity. This revealed a patent proximal superficial femoral artery in the mid vessel there was a lengthy area of severe disease extending into the proximal above-the-knee popliteal. The remainder of the popliteal artery was free of significant disease aside from a 30% stenosis at the knee. There was three-vessel runoff below the knee on the right.
*
Nonselective injection of the right iliofemoral system revealed acceptable positioning of the arterial sheath in the distal right common femoral artery above the bifurcation. As there was no disease of the site of sheath insertion, the 6 French destination sheath was exchanged for a 6 French short sheath, after which a 6 French minx device was deployed for hemostasis after confirming an activated clotting time of 168 seconds.
*
The patient was then transferred to the recovery area in stable condition.
*
Impression:
*
1. Lengthy subtotal occlusion of left SFA status post successful recanalization, angioplasty, and self-expanding stenting.
2. Three-vessel runoff below the knee on the left.
3. Moderate but nonhemodynamically significant distal left external iliac stenosis.
4. Mild right external iliac disease.
5. Severe mid to distal SFA stenosis on the right with three-vessel runoff below the knee.
6. Status post minx placement.
*
Plan:
*
1. Aspirin for life.
2. Plavix indefinitely.
3. Return in 2 weeks for left femoral access and crossover for right SFA intervention.
*I have coded 75630-xu,37226-lft,36247
please let me know if this correct or should I do 75716,37226,36247 instead?
thanks in advance
*