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one long lesion

Messages
129
Location
Greater Portland (Maine)
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0
There is one long area of occlusion from the CIA all the way down to the CFA. I coded 0238T for the atherectomy in the iliac territory, then 37221 for the stenting (multiple stents) of the one lesion, despite the fact that the stents covered 2 arteries in the iliac territory and extended into the fem-pop territory. Is this correct?

PREOPERATIVE DIAGNOSIS: Atherosclerosis with ischemic rest pain, left lower extremity.

POSTOPERATIVE DIAGNOSIS: Atherosclerosis with ischemic rest pain, left lower extremity.

NAME OF PROCEDURE:
1. Angiogram of the abdominal aorta and bilateral lower extremities.
2. Comfort stent placement, left external iliac artery (8 mm x 10 cm Viabahn).
3. Self-expanding stent placement, left external iliac artery (10 mm x 4 cm).
4. Self-expanding stent placement, left common iliac artery (10 mm x 4 cm).

SURGEON: Xxxx X Xxxxx, MD

ANESTHESIA: Local with moderate sedation.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: Flow-limiting dissection was noted following placement of the Viabahn stent. This occurred at both the upstream-most and downstream-most portions of the stent and extended for approximately 1 cm. These were areas that had been damaged by balloon angioplasty. Self-expanding stents were placed across these areas with complete resolution of this problem.
RADIOLOGIC FINDINGS:
The abdominal aorta was patent with solitary renal arteries bilaterally.

On the right side, the common iliac artery had a 50-60% stenosis in the mid segment. The right hypogastric artery was totally occluded. On the left side, the common iliac artery was patent for approximately 2.5 cm. There was a very attenuated and small appearing artery but this artery fed side branches which eventually fed the left hypogastric artery distal to its origin. In similar manner, the right sided internal iliac artery reconstituted via collaterals quite distal to its origin.

On the right side, the external iliac artery was widely patent. The common femoral artery was widely patent. The right profunda femoris and superficial femoral arteries were widely patent. These gave rise to 3-vessel runoff to the right foot. The dominant runoff vessel was the posterior tibial artery with slower flow noted in the anterior tibial artery and peroneal arteries, respectively.

On the left side, there was chronic total occlusion of the common iliac artery across the origin of the internal iliac artery and down to the level of the common femoral artery (throughout the length of the external iliac artery). In the mid common femoral artery, the common femoral reconstituted into superficial femoral and profunda femoris arteries. The left distalmost superficial femoral artery had a 70% lesion. The popliteal artery behind the knee was patent. This gave rise to anterior tibial arteries and peroneal arteries which were patent to the foot. The posterior tibial artery was a severely attenuated artery which joined one of the tarsal branches of the peroneal artery to feed the left posterior tibial artery. The peroneal artery was approximately 2.5 to 3 mm in diameter, and the posterior tibial artery was less than 1 mm in diameter. The anterior tibial artery was widely patent throughout its course.

I was able to successfully cross the left sided iliac artery lesion. This was treated with rotation atherectomy using a 1.25-mm device. This was used to treat the artery on low speed. I then performed balloon dilatation and an 8 mm x 10 cm Viabahn stent was deployed and then postdilated the areas of narrowing. This resulted in significant lifting up of intimal flaps, and this required both proximal and distal self-expanding stents to be placed. These were postdilated and the end result was a 2+ left femoral pulse and a 2+ dorsal pedal and posterior tibial pulse. I accepted this result.

PROCEDURE: The patient was taken to the cardiac catheterization laboratory where he was placed on the table in the dorsal recumbent position. After excellent moderate sedation, the skin of the right groin area was prepared and draped in the standard sterile fashion. I then accessed the right common femoral artery in the retrograde direction using ultrasound guidance and using standard Seldinger technique with a 0.018-inch micro access system. The guidewire advanced easily, and over the guidewire, a 5-French sheath was inserted. This was aspirated and flushed, and aspirated and flushed easily. Through the sheath, I then passed an Omni Flush catheter into the abdominal aorta. Then 3000 units of unfractionated heparin were administered IV. I then pulled the guidewire out of the Omni Flush catheter and advanced the catheter to the level of the L1-L2 vertebral body level. Any bubbles were removed from the catheter and I obtained an AP angiogram of the abdominal aorta. I then pulled the catheter down to the aortic bifurcation where images of the iliofemoral and pelvic arteries were obtained. Next, I selectively catheterized the left common femoral artery from the right and performed serialography of the left lower extremity as noted above.

I then removed the Omni-fluch catheter over a stiff wire, and images of the right lower extremity were then performed through the right sided sheath using serialography starting at the groin and ending at the ankle. Findings are noted above. On the right side, the superficial femoral and profunda femoris arteries were patent and there was runoff via anterior tibial, peroneal, posterior tibial artery with both anterior tibial and peroneal arteries becoming nearly occluded in the distal leg and posterior tibial artery being the dominant runoff to the right foot.

Next, I gave the patient a total of 6000 units of unfractionated heparin IV. I then used an Omni SOS catheter in conjunction with a Treasure 12 wire and was able to successfully cross the left common iliac and external iliac artery lesions. The Treasure 12 wire was exchanged for a Rosen wire. A 6-French sheath was then advanced up and over the aortic bifurcation.

I then placed a Viper wire in the left common femoral artery, and rotation atherectomy of the left common and external iliac arteries was performed at low, medium and high speeds. The artery was then predilated with a 6 mm x 10 cm scoring balloon. A Viabahn stent measuring 8 mm in diameter and 10 cm long was then carefully positioned and deployed within the lesion. The stent was found to be slightly shorter than the lesion, so I made sure that the stent was deployed in the true lumen of the artery distally, and initially ignored the proximal end point. The stent was then postdilated with an 8-mm balloon. Following 8-mm balloon angioplasty, completion angiogram showed significant dissection with stepoff of plaque both just proximal to the stent and just distal to the stent. Life stents were selected. An 8 mm x 4 cm Life stent was 1st deployed across the left distal stent into the left common femoral artery. Proximally, an 10 mm x 4 cm stent was deployed in the common iliac artery and into the stent graft. Completion arteriogram showed significant improvement. I accepted this result. Mr. Xxxxx noted burning pain into his foot as soon as revascularization occurred. I have reassured him that this was normal. Direct pressure was applied until meticulous hemostasis was achieved. A 6-French Angio-Seal device was used to close the puncture site in the right common femoral artery. The groin was re-prepared and redraped and new gloves were used. There was good hemostasis noted. Mr. Xxxx tolerated the procedure well. Sponge and needle counts, final case, were correct x2.
 
Last edited:

Jim Pawloski

True Blue
Messages
1,354
Location
Ann Arbor
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0
There is one long area of occlusion from the CIA all the way down to the CFA. I coded 0238T for the atherectomy in the iliac territory, then 37221 for the stenting (multiple stents) of the one lesion, despite the fact that the stents covered 2 arteries in the iliac territory and extended into the fem-pop territory. Is this correct?

PREOPERATIVE DIAGNOSIS: Atherosclerosis with ischemic rest pain, left lower extremity.

POSTOPERATIVE DIAGNOSIS: Atherosclerosis with ischemic rest pain, left lower extremity.

NAME OF PROCEDURE:
1. Angiogram of the abdominal aorta and bilateral lower extremities.
2. Comfort stent placement, left external iliac artery (8 mm x 10 cm Viabahn).
3. Self-expanding stent placement, left external iliac artery (10 mm x 4 cm).
4. Self-expanding stent placement, left common iliac artery (10 mm x 4 cm).

SURGEON: Xxxx X Xxxxx, MD

ANESTHESIA: Local with moderate sedation.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: Flow-limiting dissection was noted following placement of the Viabahn stent. This occurred at both the upstream-most and downstream-most portions of the stent and extended for approximately 1 cm. These were areas that had been damaged by balloon angioplasty. Self-expanding stents were placed across these areas with complete resolution of this problem.
RADIOLOGIC FINDINGS:
The abdominal aorta was patent with solitary renal arteries bilaterally.

On the right side, the common iliac artery had a 50-60% stenosis in the mid segment. The right hypogastric artery was totally occluded. On the left side, the common iliac artery was patent for approximately 2.5 cm. There was a very attenuated and small appearing artery but this artery fed side branches which eventually fed the left hypogastric artery distal to its origin. In similar manner, the right sided internal iliac artery reconstituted via collaterals quite distal to its origin.

On the right side, the external iliac artery was widely patent. The common femoral artery was widely patent. The right profunda femoris and superficial femoral arteries were widely patent. These gave rise to 3-vessel runoff to the right foot. The dominant runoff vessel was the posterior tibial artery with slower flow noted in the anterior tibial artery and peroneal arteries, respectively.

On the left side, there was chronic total occlusion of the common iliac artery across the origin of the internal iliac artery and down to the level of the common femoral artery (throughout the length of the external iliac artery). In the mid common femoral artery, the common femoral reconstituted into superficial femoral and profunda femoris arteries. The left distalmost superficial femoral artery had a 70% lesion. The popliteal artery behind the knee was patent. This gave rise to anterior tibial arteries and peroneal arteries which were patent to the foot. The posterior tibial artery was a severely attenuated artery which joined one of the tarsal branches of the peroneal artery to feed the left posterior tibial artery. The peroneal artery was approximately 2.5 to 3 mm in diameter, and the posterior tibial artery was less than 1 mm in diameter. The anterior tibial artery was widely patent throughout its course.

I was able to successfully cross the left sided iliac artery lesion. This was treated with rotation atherectomy using a 1.25-mm device. This was used to treat the artery on low speed. I then performed balloon dilatation and an 8 mm x 10 cm Viabahn stent was deployed and then postdilated the areas of narrowing. This resulted in significant lifting up of intimal flaps, and this required both proximal and distal self-expanding stents to be placed. These were postdilated and the end result was a 2+ left femoral pulse and a 2+ dorsal pedal and posterior tibial pulse. I accepted this result.

PROCEDURE: The patient was taken to the cardiac catheterization laboratory where he was placed on the table in the dorsal recumbent position. After excellent moderate sedation, the skin of the right groin area was prepared and draped in the standard sterile fashion. I then accessed the right common femoral artery in the retrograde direction using ultrasound guidance and using standard Seldinger technique with a 0.018-inch micro access system. The guidewire advanced easily, and over the guidewire, a 5-French sheath was inserted. This was aspirated and flushed, and aspirated and flushed easily. Through the sheath, I then passed an Omni Flush catheter into the abdominal aorta. Then 3000 units of unfractionated heparin were administered IV. I then pulled the guidewire out of the Omni Flush catheter and advanced the catheter to the level of the L1-L2 vertebral body level. Any bubbles were removed from the catheter and I obtained an AP angiogram of the abdominal aorta. I then pulled the catheter down to the aortic bifurcation where images of the iliofemoral and pelvic arteries were obtained. Next, I selectively catheterized the left common femoral artery from the right and performed serialography of the left lower extremity as noted above.

I then removed the Omni-fluch catheter over a stiff wire, and images of the right lower extremity were then performed through the right sided sheath using serialography starting at the groin and ending at the ankle. Findings are noted above. On the right side, the superficial femoral and profunda femoris arteries were patent and there was runoff via anterior tibial, peroneal, posterior tibial artery with both anterior tibial and peroneal arteries becoming nearly occluded in the distal leg and posterior tibial artery being the dominant runoff to the right foot.

Next, I gave the patient a total of 6000 units of unfractionated heparin IV. I then used an Omni SOS catheter in conjunction with a Treasure 12 wire and was able to successfully cross the left common iliac and external iliac artery lesions. The Treasure 12 wire was exchanged for a Rosen wire. A 6-French sheath was then advanced up and over the aortic bifurcation.

I then placed a Viper wire in the left common femoral artery, and rotation atherectomy of the left common and external iliac arteries was performed at low, medium and high speeds. The artery was then predilated with a 6 mm x 10 cm scoring balloon. A Viabahn stent measuring 8 mm in diameter and 10 cm long was then carefully positioned and deployed within the lesion. The stent was found to be slightly shorter than the lesion, so I made sure that the stent was deployed in the true lumen of the artery distally, and initially ignored the proximal end point. The stent was then postdilated with an 8-mm balloon. Following 8-mm balloon angioplasty, completion angiogram showed significant dissection with stepoff of plaque both just proximal to the stent and just distal to the stent. Life stents were selected. An 8 mm x 4 cm Life stent was 1st deployed across the left distal stent into the left common femoral artery. Proximally, an 10 mm x 4 cm stent was deployed in the common iliac artery and into the stent graft. Completion arteriogram showed significant improvement. I accepted this result. Mr. Xxxxx noted burning pain into his foot as soon as revascularization occurred. I have reassured him that this was normal. Direct pressure was applied until meticulous hemostasis was achieved. A 6-French Angio-Seal device was used to close the puncture site in the right common femoral artery. The groin was re-prepared and redraped and new gloves were used. There was good hemostasis noted. Mr. Xxxx tolerated the procedure well. Sponge and needle counts, final case, were correct x2.
I would code for the common femoral artery, since the report states that the stent went into the common femoral artery. So use 37226 with your other codes.
HTH,
Jim Pawloski, CIRCC
 
Messages
129
Location
Greater Portland (Maine)
Best answers
0
I wasn't sure because he was still treating the single lesion which started in the lt CIA and extended throughout the length of the EIA, and CPT book states "if lesion extends across the margins of one vessel vascular terriotyr into another, but can be opened with a single therapy, this intervention should be reported with a single code despite treating more than one vessel and/or vascular territory. In essence, he was extending the initially-placed Viabahn stent both proximally and distally. I've never encountered this problem before, so not sure. Am I misinterpreting this guidance? I'm still a little at sea with this.
Thank you for your wisdom. I do appreciate it.
Rita
 
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