em2177
Expert
NEED SOME ASSISTANCE IN CODING THIS REPORT. THANK YOU!!! 
REASON FOR EVALUATION: Claudication.
HISTORY OF THE PRESENT ILLNESS: This patient is well-known to me for severe
peripheral arterial disease. I recently fixed his right lower extremity for
severe in-stent restenosis. The patient now comes here for further evaluation
of the left lower extremity. He states his right lower extremity is much
improved. However, his left lower extremity is significantly limiting him.
Over the last couple of days he had some mild left lower abdominal quadrant
pain with no other Gl complaints, somewhat vague in nature.
The patient has been explained the risks, benefits, and alternatives of
peripheral angiography and possible angioplasty and stenting, and agrees to
proceed.
PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Lidocaine was placed at the right
common femoral area. Using a micropuncture technique, a 6-French sheath was
placed to the right common femoral artery. Next, a LIMA catheter was placed
over the long Glidewire to the level of the proximal left iliac and common
iliac, and angiography down the iliac system was performed. Then the Glidewire
was placed further distally and the catheter was placed to the left common
femoral artery. Angiography was performed down the leg to the level of the
ankle.
Next the wire was left in place. The LIMA catheter was removed. The short
6-French sheath was removed, and a 6-French Ansel sheath was
placed over the wire to the level of the left common femoral artery. The
Glidewire was in the popliteal artery, and balloon dilatation of the distal SFA
was performed with a 5 x 60 EverCross balloon to 10 atmospheres. Then, at the
level of the proximal-to-mid SFA there was serial balloon angioplasty just
proximal to an old prior stent. Balloon was removed and angiography down the
left leg was performed. There was significant improvement of flow throughout
the left popliteal and left SFA. The proximal-to-mid SFA remained diffusely
diseased, greater than 30%.
Stenting was performed with a 6 x 150 Protege stent which is self-expanding,
and then post dilatation was performed with a 6.0 balloon over the entire
stented segment. Balloon was removed. Angiography down the groin was
performed.
Next, wire was removed. The Ansel sheath was placed to the right side. ACT
was performed, and then manual pressure to the right common femoral artery was
held per standard protocol with good groin hemostasis and no evidence of
oozing, bruising, or hematoma.
The patient tolerated the procedure well and remained hemodynamically stable
and asymptomatic.
REASON FOR EVALUATION: Claudication.
HISTORY OF THE PRESENT ILLNESS: This patient is well-known to me for severe
peripheral arterial disease. I recently fixed his right lower extremity for
severe in-stent restenosis. The patient now comes here for further evaluation
of the left lower extremity. He states his right lower extremity is much
improved. However, his left lower extremity is significantly limiting him.
Over the last couple of days he had some mild left lower abdominal quadrant
pain with no other Gl complaints, somewhat vague in nature.
The patient has been explained the risks, benefits, and alternatives of
peripheral angiography and possible angioplasty and stenting, and agrees to
proceed.
PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Lidocaine was placed at the right
common femoral area. Using a micropuncture technique, a 6-French sheath was
placed to the right common femoral artery. Next, a LIMA catheter was placed
over the long Glidewire to the level of the proximal left iliac and common
iliac, and angiography down the iliac system was performed. Then the Glidewire
was placed further distally and the catheter was placed to the left common
femoral artery. Angiography was performed down the leg to the level of the
ankle.
Next the wire was left in place. The LIMA catheter was removed. The short
6-French sheath was removed, and a 6-French Ansel sheath was
placed over the wire to the level of the left common femoral artery. The
Glidewire was in the popliteal artery, and balloon dilatation of the distal SFA
was performed with a 5 x 60 EverCross balloon to 10 atmospheres. Then, at the
level of the proximal-to-mid SFA there was serial balloon angioplasty just
proximal to an old prior stent. Balloon was removed and angiography down the
left leg was performed. There was significant improvement of flow throughout
the left popliteal and left SFA. The proximal-to-mid SFA remained diffusely
diseased, greater than 30%.
Stenting was performed with a 6 x 150 Protege stent which is self-expanding,
and then post dilatation was performed with a 6.0 balloon over the entire
stented segment. Balloon was removed. Angiography down the groin was
performed.
Next, wire was removed. The Ansel sheath was placed to the right side. ACT
was performed, and then manual pressure to the right common femoral artery was
held per standard protocol with good groin hemostasis and no evidence of
oozing, bruising, or hematoma.
The patient tolerated the procedure well and remained hemodynamically stable
and asymptomatic.