herrera4
Guru
Hi!! i am having a really hard time understanding the new 2017 codes--can someone help me with this op note ? walk me through it? or give me the best articles-i dont have the best resources(i.e nothing that cost anything) thank you
1. Left brachial approach second order aortogram.2. Bilateral renal artery angioplasty.3. Left brachial artery exploration and repair.
DESCRIPTION OF PROCEDURE: Ms. was brought to the hybrid suite on January 24, 2017. The patient was prepped and draped in the usual sterile fashion in preparation for left brachial percutaneous approach. The patient was anesthetized under conscious sedation with anesthesia. A micropuncture needle was used to access the left brachial artery and microsheath was inserted over a micro wire. We placed an 0.35 J wire through the micro sheath. Using a combination of an angled glide catheter followed by long, stiff glide wire, we were able to fluoroscopically enter the descending thoracic aorta. We advanced the stiff glide wire into the infrarenal abdominal aorta. At that point, we performed aortogram. This revealed the location of both renal arteries. We then cannulated the left renal artery with the angled glide catheter and performed a third order selective renal angiogram. This delineated the anatomy of the fibromuscular dysplastic renal artery at the secondary branches just proximal to the hilum of the kidney. We then advanced a stiff 0.035 glide wire across the stenotic segment. We advanced a 5 French Ansel sheath through the left brachial artery access site into the orifice of the left renal artery. Using road map imaging, we then performed angioplasty of the stenotic, dysplastic segment using a 6 x 4 mm angioplasty balloon. Completion angiography revealed significant improvement with minimal recoil after the procedure.
We then retracted the Ansel sheath from the orifice of the left renal artery. We removed the balloon over an 0.035 glide wire. We then cannulated the right renal artery using an angled glide catheter and 0.014 PT Choice wire. We then advanced the Ansel sheath into the orifice of the right renal artery and performed a third order selective renal artery angiogram. This showed an even more distal location of the fibromuscular dysplastic segment. The decision was made to use a smaller platform wire, 0.014 wire to perform this intervention. Under fluoroscopic guidance, the right fibromuscular dysplastic segment was crossed over which we sequentially performed angioplasty with 4 x 2 and 5 x 2 mm balloon. Completion angiography revealed excellent result. This procedure was done after Heparin 9000 units was given and allowed to circulate for three minutes. Once completed, all catheters, sheaths and wires were removed. Digital pressure was held for hemostasis at the left brachial artery puncture site.
We held pressure for 20 minutes, after which time examination showed the presence of moderate sized hematoma at the medial portion of the patient's biceps muscle. Out of precaution, we decided to explore the brachial artery by performing 4 cm incision over the puncture site. We then dissected down to the brachial artery. At that point, we removed a moderate amount of hematoma from the brachial space as well as from the area just above the puncture sites on the brachial artery.
Once retractors were placed, there was a small arteriotomy. This had not completely thrombosed. We did a primary repair of the puncture site with 6-0 Prolene suture. We then closed the incision with Vicryl running suture. We reapproximated the skin with clips. She had a pulse in the radial artery at the conclusion of the procedure, after which point we wrapped her arm in an Ace bandage and discharged her ....
if you made it to the end-i appreciate it
1. Left brachial approach second order aortogram.2. Bilateral renal artery angioplasty.3. Left brachial artery exploration and repair.
DESCRIPTION OF PROCEDURE: Ms. was brought to the hybrid suite on January 24, 2017. The patient was prepped and draped in the usual sterile fashion in preparation for left brachial percutaneous approach. The patient was anesthetized under conscious sedation with anesthesia. A micropuncture needle was used to access the left brachial artery and microsheath was inserted over a micro wire. We placed an 0.35 J wire through the micro sheath. Using a combination of an angled glide catheter followed by long, stiff glide wire, we were able to fluoroscopically enter the descending thoracic aorta. We advanced the stiff glide wire into the infrarenal abdominal aorta. At that point, we performed aortogram. This revealed the location of both renal arteries. We then cannulated the left renal artery with the angled glide catheter and performed a third order selective renal angiogram. This delineated the anatomy of the fibromuscular dysplastic renal artery at the secondary branches just proximal to the hilum of the kidney. We then advanced a stiff 0.035 glide wire across the stenotic segment. We advanced a 5 French Ansel sheath through the left brachial artery access site into the orifice of the left renal artery. Using road map imaging, we then performed angioplasty of the stenotic, dysplastic segment using a 6 x 4 mm angioplasty balloon. Completion angiography revealed significant improvement with minimal recoil after the procedure.
We then retracted the Ansel sheath from the orifice of the left renal artery. We removed the balloon over an 0.035 glide wire. We then cannulated the right renal artery using an angled glide catheter and 0.014 PT Choice wire. We then advanced the Ansel sheath into the orifice of the right renal artery and performed a third order selective renal artery angiogram. This showed an even more distal location of the fibromuscular dysplastic segment. The decision was made to use a smaller platform wire, 0.014 wire to perform this intervention. Under fluoroscopic guidance, the right fibromuscular dysplastic segment was crossed over which we sequentially performed angioplasty with 4 x 2 and 5 x 2 mm balloon. Completion angiography revealed excellent result. This procedure was done after Heparin 9000 units was given and allowed to circulate for three minutes. Once completed, all catheters, sheaths and wires were removed. Digital pressure was held for hemostasis at the left brachial artery puncture site.
We held pressure for 20 minutes, after which time examination showed the presence of moderate sized hematoma at the medial portion of the patient's biceps muscle. Out of precaution, we decided to explore the brachial artery by performing 4 cm incision over the puncture site. We then dissected down to the brachial artery. At that point, we removed a moderate amount of hematoma from the brachial space as well as from the area just above the puncture sites on the brachial artery.
Once retractors were placed, there was a small arteriotomy. This had not completely thrombosed. We did a primary repair of the puncture site with 6-0 Prolene suture. We then closed the incision with Vicryl running suture. We reapproximated the skin with clips. She had a pulse in the radial artery at the conclusion of the procedure, after which point we wrapped her arm in an Ace bandage and discharged her ....
if you made it to the end-i appreciate it