Rita Bartholomew
Guru
I know that intraprocedural thrombolyis is bundled with percutaneous thrombectomy, but can I add 37201/75896 in this case in which there was over 2 hrs of thrombolysis? The other assigned codes, along with 37184, are 75625, 75716, 37225 and 76937. Thank you.
PREOPERATIVE DIAGNOSIS: Atherosclerosis and ischemic rest pain of the left lower extremity, failed left lower extremity bypass graft.
POSTOPERATIVE DIAGNOSIS: Atherosclerosis and ischemic rest pain of the left lower extremity, failed left lower extremity bypass graft.
PROCEDURE PERFORMED:
1. Angiogram of the abdominal aorta and bilateral lower extremities.
2. Percutaneous thrombectomy with lytic therapy of the patient's left lower extremity bypass.
3. Rotational atherectomy and angioplasty of the left profunda femoris artery.
4. Balloon angioplasty (6 mm x 40 mm) left femoral to popliteal artery bypass graft at the distal anastomosis.
5. Ultrasound guided access to the right common femoral artery.
SURGEON: Xxxx Xxxxx, M.D.
ANESTHESIA: Local with moderate sedation x3 hours.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CLINICAL HISTORY: This 75-year-old male with mixed connective tissue disorder and advanced atherosclerosis has had numerous interventions in both lower extremities. He has had right sided iliac artery aneurysms treated with stent graft and he has had stents placed in the left external iliac artery as well. The left femoral to popliteal artery bypass with PTFE and vein cuff has also been placed. Approximately 1 year ago, he underwent percutaneous thrombectomy with lytic therapy of the left lower extremity bypass with success and comes back with a severely ischemic left lower extremity for several days.
He has significant scar tissue in both groin areas due to his previous interventions, so ultrasound guided access was needed for safety.
His procedure was more difficult than usual due to the extensive previous intervention history and advanced ischemia of the left leg, so a 22-modifier has been added to the usual procedural codes.
RADIOLOGIC FINDINGS:
1. The abdominal aorta was patent with solitary renal arteries bilaterally. The right renal artery was slightly lower than the left and had excentric calcifications at its inferior edge. The left renal artery bifurcated approximately 1.5 cm from its origin. Both kidneys were of reasonable size.
2. The abdominal aorta was calcific with some aneurysmal change.
3. On the right side, the common iliac artery had a 40 to 50% stenosis in the proximal 1 cm. Just distal to this was a stent graft spanning the entire length of the common iliac artery and into the external iliac artery. The right hypogastric artery was completely occluded. The right external iliac artery was widely patent as was the right common femoral artery, which had surgical changes consistent with prior endarterectomy.
4. On the left side, the common iliac artery appeared to be diseased with calcification but no focal stenosis. The left hypogastric artery had a trickle of flow in it which was minimal. A large median sacral artery was noted.
5. On the left side, the external iliac artery was widely patent and the common femoral artery had surgical change consistent with prior bypass. The bypass graft was chronically, totally occluded. The superficial femoral artery was chronically, totally occluded. The profunda femoris artery was severely stenotic for approximately 90% throughout much of its length with a dense calcification and gave rise to a 3 mm runoff vessel which was the main artery feeding the entire leg.
The total occlusion of the superficial femoral artery extended down to the above-the-knee popliteal artery. The native superficial artery, although occluded, was very densely calcified.
Back to the right side, the right common femoral artery was patent as was the profunda femoris and superficial femoral arteries. The right superficial femoral artery was noted to have a stent extending from the distal SFA and into the above-the-knee popliteal artery. This stent was widely patent. The right popliteal artery then remained patent to below the level of the knee. Below the knee, there was runoff via perineal and posterior tibial arteries which were severely calcified and extremely small. These were note well visualized into the lower leg or foot on the right. There was a very tiny-appearing anterior tibial artery in the right foot.
On the left side, the popliteal artery, where is reconstituted remained patent and gave rise to a posterior tibial and perineal arteries as well as a proximal anterior tibial artery which appeared to be totally occluded approximately 2 cm from its origin. The posterior tibial artery appeared to be the dominant runoff to the left foot. The perineal artery was extremely small; both arteries had no appreciable flow in the lower 3rd of the leg and into the foot.
I was able to successfully cross the chronic total occlusion of the bypass graft. I then used a Possis device to perform power-pulse directed lysis of the bypass graft by infusing the occluded bypass graft throughout 90% of its length with tPA, leaving it for 15 to 20 minutes, and then aspirating the resultant slurry. Significant thrombus was removed from the graft. This was repeated 3 times and the 3rd time going through the entire bypass. Upon completion, the bypass graft was widely patent into the popliteal artery, but a severe stricture at the level of the vein cuff was noted to be present. This stricture was dilated with a scoring balloon measuring 6 mm x 40 mm with a good result. The runoff upon completion was pertinent for perineal artery runoff but the posterior tibial artery appeared totally occluded and the anterior tibial artery was patent for approximately 12 cm and then became chronically, totally occluded for approximately 3 to 4 cm with thrombus. Vasodilators were given, and after further heparinization and time, there appeared to be 3-vessel runoff with segments of total occlusion in the posterior tibial and anterior tibial arteries as well as the distal most perineal artery. As lysis was ongoing with significant systemic lytic therapy circulating, I decided to accept this result.
I was then able to successfully cross the left profunda femoris artery stenosis. At this time, the proximal portion of the bypass graft seemed significantly strictured and so upon completion, this was also dilated with a 6 mm balloon.
Rotational atherectomy of the profunda femoris artery was performed with the 1.25 mm CSI device at low, medium, and high speeds. This was then treated with angioplasty using a 4 mm x 4 cm angio sculpt balloon with an excellent result.
The proximal lesion in the bypass graft did not appear to respond to the balloon angioplasty using the 6 mm balloon.
Final completion arteriogram showed continuous flow via the posterior tibial artery, continued total occlusion of the anterior tibial artery and a patent perineal artery into the lower leg.
I accepted this result and a Mynx closure device was used to close the puncture site in the right groin area.
OPERATIVE REPORT: The patient was taken to the Cardiac Catheterization laboratory where he was placed on the table in a dorsal recumbent position.
Following excellent monitored sedation, the skin of the groin areas was prepared and draped in a standard sterile fashion. I then called a time out for correct patient and procedural identification per Xxxxx Hospital protocol. Next, using local anesthesia and color flow duplex ultrasound guidance, I accessed the right common femoral artery. Significant scar tissue was encountered. Images of the ultrasound access were achieved to PACS.
Next, I introduced a 5-French sheath into the right common femoral artery and aspirated and flushed the sheath. Three thousand units of unfractionated heparin were administered IV. Next, through the sheath, I advanced an Omni Flush Catheter into the abdominal aorta at the L1/L2 vertebral body level. The guidewire was removed and the Omni flush Catheter was fashioned. Bubbles were removed and an AP angiogram of the abdominal aorta was then obtained.
I then pulled the catheter down to the aortic bifurcation where black imaging of the ileofemoral and pelvic runoff was obtained.
Embolus chase arteriogram of both lower extremities was performed maintaining the position of the catheter in the distal abdominal aorta.
Next, I decided to obtain up and over access to the left common femoral artery, and so a stiff wire was placed into the left common femoral artery and over the stiff wire, a 6-French sheath was advanced up and over the aortic bifurcation. A Bulk and Sheath was chosen. After this, I heparinized the patient with 70 mg/kg on fraction at heparin IV. After this, using a Glide Catheter and Glidewire combination, I was able to successfully selectively catheterize the patient's totally occluded bypass. I was able to pass the Glide Catheter down all the way into the distal anastomosis of the bypass graft. Imaging of the left lower extremity verified position in the true lumen of the left above-the-knee popliteal artery. Significant stricture was noted at the distal anastomosis with made guidewire access difficult.
Further images of the left lower extremity were then obtained, after crossing the area of total occlusion.
I then placed a stiff guidewire into the popliteal artery. A Possis device was selected appropriate for the size of the bypass graft and a power pulse technique was selected in which 25 mg of tPA was dissolved in 250 mL of normal saline. I then used power pulse technique to lyse the bypass by first lacing the occluded bypass with tPA using the power pulse technique. The catheter was left in the distal bypass graft, not yet crossing totally across the total occlusions distal end and into the native circulation. I left the tPA there for approximately 158 minutes, and then aspirated the tPA using standard thrombectomy with the Possis device. Once again, I laced the bypass graft through nearly all of its length with more tPA, and waited an additional 15 minutes to 20 minutes after which time, I aspirated the thrombus using the Possis device. On the 3rd time, I performed an arteriogram of the bypass graft and this demonstrated that it was almost completely open except for the distal-most portion and so power pulse was then used on the distal most portion of the bypass graft into the native artery. Another 15 minutes was allowed to elapse at which time I aspirated everything using the Possis device and performed a completion arteriogram. This now demonstrated wide patency of the bypass graft throughout its length with the exception of the distal anastomotic area, which was represented the Miller vein cuff. This was then treated using a 4 mm x 40 mm angio sculpt balloon. Completion arteriogram is as noted above and there was evidence of distal embolization into anterior tibial, perineal and posterior tibial arteries. At this point, I directed my therapy to the more proximal arteries and the profunda femoris artery was noted to be severely stenotic. With great difficulty in using the Glide Catheter in accommodation with the PT Graphix wire, I was able to selectively catheterize the patient's distal profunda femoris artery. I was able to exchange this for a 0.014 inch Viper wire and then I selected a 1.25 mm standard crown CSI atherectomy device and treated the artery at low speed, medium speed, and high speeds. Two runs at each speed were performed and this was followed by a 3rd and 4th run at high speed. Thirty-second runs were used with 30 second intervals in between treatments. Next, the 4 mm x 4 cm scoring balloon was then used to treat the profunda femoris artery. Completion arteriogram showed significant improvement although there was still a stenosis noted in the most proximal portion of the bypass graft. At its origin, there appeared to be a 40 to 50 to 60% stenosis which was excentric. I then selected to catheterize the bypass graft again and use the scoring balloon to treat the proximal most portion of the bypass graft. A 1-minute inflation was used at full effacement and nominal pressure. Completion arteriogram showed no significant change in the lesion, and I presumed there was significant recoil. I decided to accept this result. Further completion arteriogram was performed with the Glide Catheter placed in the distal bypass graft and this demonstrated significant improvement of the flow in the left lower extremity and resolution of some of the chronic total occlusion in the tibial arteries. The foot appeared to be significantly better perfused and I accepted this result. I then reprepped and redraped the right groin area and a Mynx closure device, 6-French was used to close the puncture site in the right groin area. A dry sterile dressing was applied. There were no complications and the patient tolerated the procedure well. Sponge and needle counts in the case were correct x2. For flow times and contrast use please refer to the nursing notes.
PREOPERATIVE DIAGNOSIS: Atherosclerosis and ischemic rest pain of the left lower extremity, failed left lower extremity bypass graft.
POSTOPERATIVE DIAGNOSIS: Atherosclerosis and ischemic rest pain of the left lower extremity, failed left lower extremity bypass graft.
PROCEDURE PERFORMED:
1. Angiogram of the abdominal aorta and bilateral lower extremities.
2. Percutaneous thrombectomy with lytic therapy of the patient's left lower extremity bypass.
3. Rotational atherectomy and angioplasty of the left profunda femoris artery.
4. Balloon angioplasty (6 mm x 40 mm) left femoral to popliteal artery bypass graft at the distal anastomosis.
5. Ultrasound guided access to the right common femoral artery.
SURGEON: Xxxx Xxxxx, M.D.
ANESTHESIA: Local with moderate sedation x3 hours.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CLINICAL HISTORY: This 75-year-old male with mixed connective tissue disorder and advanced atherosclerosis has had numerous interventions in both lower extremities. He has had right sided iliac artery aneurysms treated with stent graft and he has had stents placed in the left external iliac artery as well. The left femoral to popliteal artery bypass with PTFE and vein cuff has also been placed. Approximately 1 year ago, he underwent percutaneous thrombectomy with lytic therapy of the left lower extremity bypass with success and comes back with a severely ischemic left lower extremity for several days.
He has significant scar tissue in both groin areas due to his previous interventions, so ultrasound guided access was needed for safety.
His procedure was more difficult than usual due to the extensive previous intervention history and advanced ischemia of the left leg, so a 22-modifier has been added to the usual procedural codes.
RADIOLOGIC FINDINGS:
1. The abdominal aorta was patent with solitary renal arteries bilaterally. The right renal artery was slightly lower than the left and had excentric calcifications at its inferior edge. The left renal artery bifurcated approximately 1.5 cm from its origin. Both kidneys were of reasonable size.
2. The abdominal aorta was calcific with some aneurysmal change.
3. On the right side, the common iliac artery had a 40 to 50% stenosis in the proximal 1 cm. Just distal to this was a stent graft spanning the entire length of the common iliac artery and into the external iliac artery. The right hypogastric artery was completely occluded. The right external iliac artery was widely patent as was the right common femoral artery, which had surgical changes consistent with prior endarterectomy.
4. On the left side, the common iliac artery appeared to be diseased with calcification but no focal stenosis. The left hypogastric artery had a trickle of flow in it which was minimal. A large median sacral artery was noted.
5. On the left side, the external iliac artery was widely patent and the common femoral artery had surgical change consistent with prior bypass. The bypass graft was chronically, totally occluded. The superficial femoral artery was chronically, totally occluded. The profunda femoris artery was severely stenotic for approximately 90% throughout much of its length with a dense calcification and gave rise to a 3 mm runoff vessel which was the main artery feeding the entire leg.
The total occlusion of the superficial femoral artery extended down to the above-the-knee popliteal artery. The native superficial artery, although occluded, was very densely calcified.
Back to the right side, the right common femoral artery was patent as was the profunda femoris and superficial femoral arteries. The right superficial femoral artery was noted to have a stent extending from the distal SFA and into the above-the-knee popliteal artery. This stent was widely patent. The right popliteal artery then remained patent to below the level of the knee. Below the knee, there was runoff via perineal and posterior tibial arteries which were severely calcified and extremely small. These were note well visualized into the lower leg or foot on the right. There was a very tiny-appearing anterior tibial artery in the right foot.
On the left side, the popliteal artery, where is reconstituted remained patent and gave rise to a posterior tibial and perineal arteries as well as a proximal anterior tibial artery which appeared to be totally occluded approximately 2 cm from its origin. The posterior tibial artery appeared to be the dominant runoff to the left foot. The perineal artery was extremely small; both arteries had no appreciable flow in the lower 3rd of the leg and into the foot.
I was able to successfully cross the chronic total occlusion of the bypass graft. I then used a Possis device to perform power-pulse directed lysis of the bypass graft by infusing the occluded bypass graft throughout 90% of its length with tPA, leaving it for 15 to 20 minutes, and then aspirating the resultant slurry. Significant thrombus was removed from the graft. This was repeated 3 times and the 3rd time going through the entire bypass. Upon completion, the bypass graft was widely patent into the popliteal artery, but a severe stricture at the level of the vein cuff was noted to be present. This stricture was dilated with a scoring balloon measuring 6 mm x 40 mm with a good result. The runoff upon completion was pertinent for perineal artery runoff but the posterior tibial artery appeared totally occluded and the anterior tibial artery was patent for approximately 12 cm and then became chronically, totally occluded for approximately 3 to 4 cm with thrombus. Vasodilators were given, and after further heparinization and time, there appeared to be 3-vessel runoff with segments of total occlusion in the posterior tibial and anterior tibial arteries as well as the distal most perineal artery. As lysis was ongoing with significant systemic lytic therapy circulating, I decided to accept this result.
I was then able to successfully cross the left profunda femoris artery stenosis. At this time, the proximal portion of the bypass graft seemed significantly strictured and so upon completion, this was also dilated with a 6 mm balloon.
Rotational atherectomy of the profunda femoris artery was performed with the 1.25 mm CSI device at low, medium, and high speeds. This was then treated with angioplasty using a 4 mm x 4 cm angio sculpt balloon with an excellent result.
The proximal lesion in the bypass graft did not appear to respond to the balloon angioplasty using the 6 mm balloon.
Final completion arteriogram showed continuous flow via the posterior tibial artery, continued total occlusion of the anterior tibial artery and a patent perineal artery into the lower leg.
I accepted this result and a Mynx closure device was used to close the puncture site in the right groin area.
OPERATIVE REPORT: The patient was taken to the Cardiac Catheterization laboratory where he was placed on the table in a dorsal recumbent position.
Following excellent monitored sedation, the skin of the groin areas was prepared and draped in a standard sterile fashion. I then called a time out for correct patient and procedural identification per Xxxxx Hospital protocol. Next, using local anesthesia and color flow duplex ultrasound guidance, I accessed the right common femoral artery. Significant scar tissue was encountered. Images of the ultrasound access were achieved to PACS.
Next, I introduced a 5-French sheath into the right common femoral artery and aspirated and flushed the sheath. Three thousand units of unfractionated heparin were administered IV. Next, through the sheath, I advanced an Omni Flush Catheter into the abdominal aorta at the L1/L2 vertebral body level. The guidewire was removed and the Omni flush Catheter was fashioned. Bubbles were removed and an AP angiogram of the abdominal aorta was then obtained.
I then pulled the catheter down to the aortic bifurcation where black imaging of the ileofemoral and pelvic runoff was obtained.
Embolus chase arteriogram of both lower extremities was performed maintaining the position of the catheter in the distal abdominal aorta.
Next, I decided to obtain up and over access to the left common femoral artery, and so a stiff wire was placed into the left common femoral artery and over the stiff wire, a 6-French sheath was advanced up and over the aortic bifurcation. A Bulk and Sheath was chosen. After this, I heparinized the patient with 70 mg/kg on fraction at heparin IV. After this, using a Glide Catheter and Glidewire combination, I was able to successfully selectively catheterize the patient's totally occluded bypass. I was able to pass the Glide Catheter down all the way into the distal anastomosis of the bypass graft. Imaging of the left lower extremity verified position in the true lumen of the left above-the-knee popliteal artery. Significant stricture was noted at the distal anastomosis with made guidewire access difficult.
Further images of the left lower extremity were then obtained, after crossing the area of total occlusion.
I then placed a stiff guidewire into the popliteal artery. A Possis device was selected appropriate for the size of the bypass graft and a power pulse technique was selected in which 25 mg of tPA was dissolved in 250 mL of normal saline. I then used power pulse technique to lyse the bypass by first lacing the occluded bypass with tPA using the power pulse technique. The catheter was left in the distal bypass graft, not yet crossing totally across the total occlusions distal end and into the native circulation. I left the tPA there for approximately 158 minutes, and then aspirated the tPA using standard thrombectomy with the Possis device. Once again, I laced the bypass graft through nearly all of its length with more tPA, and waited an additional 15 minutes to 20 minutes after which time, I aspirated the thrombus using the Possis device. On the 3rd time, I performed an arteriogram of the bypass graft and this demonstrated that it was almost completely open except for the distal-most portion and so power pulse was then used on the distal most portion of the bypass graft into the native artery. Another 15 minutes was allowed to elapse at which time I aspirated everything using the Possis device and performed a completion arteriogram. This now demonstrated wide patency of the bypass graft throughout its length with the exception of the distal anastomotic area, which was represented the Miller vein cuff. This was then treated using a 4 mm x 40 mm angio sculpt balloon. Completion arteriogram is as noted above and there was evidence of distal embolization into anterior tibial, perineal and posterior tibial arteries. At this point, I directed my therapy to the more proximal arteries and the profunda femoris artery was noted to be severely stenotic. With great difficulty in using the Glide Catheter in accommodation with the PT Graphix wire, I was able to selectively catheterize the patient's distal profunda femoris artery. I was able to exchange this for a 0.014 inch Viper wire and then I selected a 1.25 mm standard crown CSI atherectomy device and treated the artery at low speed, medium speed, and high speeds. Two runs at each speed were performed and this was followed by a 3rd and 4th run at high speed. Thirty-second runs were used with 30 second intervals in between treatments. Next, the 4 mm x 4 cm scoring balloon was then used to treat the profunda femoris artery. Completion arteriogram showed significant improvement although there was still a stenosis noted in the most proximal portion of the bypass graft. At its origin, there appeared to be a 40 to 50 to 60% stenosis which was excentric. I then selected to catheterize the bypass graft again and use the scoring balloon to treat the proximal most portion of the bypass graft. A 1-minute inflation was used at full effacement and nominal pressure. Completion arteriogram showed no significant change in the lesion, and I presumed there was significant recoil. I decided to accept this result. Further completion arteriogram was performed with the Glide Catheter placed in the distal bypass graft and this demonstrated significant improvement of the flow in the left lower extremity and resolution of some of the chronic total occlusion in the tibial arteries. The foot appeared to be significantly better perfused and I accepted this result. I then reprepped and redraped the right groin area and a Mynx closure device, 6-French was used to close the puncture site in the right groin area. A dry sterile dressing was applied. There were no complications and the patient tolerated the procedure well. Sponge and needle counts in the case were correct x2. For flow times and contrast use please refer to the nursing notes.
