penswhitex
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Looking for some help, new to vascular and right off the bat one of the codes the physician gave me is deleted, Ugh!
Operation:
1. Placement of a left renal artery catheter through right common femoral artery approach.
2. Ultrasound guidance for arterial access.
3. Selective left renal angiograms.
4. Percutaneous transluminal balloon angioplasty of the left renal artery.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, was placed in the supine position. She was induced under general anesthesia by LMA smoothly. The abdomen and thighs were prepped and draped in a sterile fashion. The portable ultrasound unit was used to assess the right common femoral artery, and under US guidance an 18-gauge needle was placed into the right common femoral artery without difficulty. A guidewire was advanced. A small skin nick was made and a 6-French introducer sheath was placed. The patient received 5000 units of heparin intravenously, which was supplemented through the procedure. A 0.035 Glidewire was then advanced into the proximal aorta. The short 6-French sheath was exchanged for a 45 cm 6-French pinnacle destination sheath with a curved tip, which was advanced up to the level of the renal arteries. The catheter tip was manipulated into the left renal artery. The curved nature of the midportion of the renal artery together with a severe stenosis made it very difficult to pass the guidewire through this area. Eventually, however, the guidewire was advanced through the stenosis and out into a branch renal artery. The Quick-Cross catheter was advanced over the wire and it was also difficult to pass the Quick-Cross catheter through the stenosis as well, but eventually this was successful. The Glidewire was exchanged for a 0.018 guidewire. The tip of the sheath was advanced to the orifice of the left renal artery, and a selective angiogram was repeated at this point due to the torque from the curve of the renal artery, we lost the wire and it was very difficult to reintroduce the wire, but after switching to a 0.035 stiff-angled Glidewire, eventually the wire was able to be advanced back into the renal artery. The Quick-Cross catheter was advanced and we went throught a couple of episodes of losing the guidewire and having to start from the beginning again, but eventually the wire was reintroduced and we were able to pass the Quick-Cross catheter through to the distal renal artery. We then exchanged to a 0.014 command wire, which was able to be advanced throught the Quick-Cross catheter, and out into a renal artery branch. Quick-Cross catheter was removed, and a 4 mm x 2 cm balloon angioplasty catheter was advanced over the wire through the area of stenosis and inflated up to 4 atmospheres of pressure for 1 minute. Balloon catheter was removed and with removing the catheter again we lost the wire. The wire was reintroduced and a repeat angiogram revealed a fairly good result with just some very minimal recurrent stenosis in the area. The nephrogram, due to the chronic renal disease, really did not improve in any significant way after the balloon angioplasty. I wanted to place a stent and it has been quite a lot of time reintroducing a catheter. The wire was again lost and we changed to an SOS catheter, which did facilitate reintroducing the wire again and we made several attempts to exchange the Glidewire for a smaller wire. Eventually, the wire was introduced and we attempted to pass a 5-mm stent, but unfortunately the wire was lost again. Several additional attempts were made, but I was never able to pass the stent catheter over the wire. Another completion arteriogram was performed, which again revealed patency of the stenotic area and no change to the nephrogram, and so the procedure was stopped at this point. The introducer sheath was exchanged for the introducer for a StarClose device and I attempted to deploy this but did not achieve hemostasis so pressure was held with a QuikClot pad for 15 mins.
The rest just explains closing and everything. Sorry this is so lengthy but I didn't want to leave anything out.
These are the codes that I came up with: 35471, 36251 and 76942,26.
Any help as well as explanation or teaching will be greatly appreciated. Thanks.
Operation:
1. Placement of a left renal artery catheter through right common femoral artery approach.
2. Ultrasound guidance for arterial access.
3. Selective left renal angiograms.
4. Percutaneous transluminal balloon angioplasty of the left renal artery.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, was placed in the supine position. She was induced under general anesthesia by LMA smoothly. The abdomen and thighs were prepped and draped in a sterile fashion. The portable ultrasound unit was used to assess the right common femoral artery, and under US guidance an 18-gauge needle was placed into the right common femoral artery without difficulty. A guidewire was advanced. A small skin nick was made and a 6-French introducer sheath was placed. The patient received 5000 units of heparin intravenously, which was supplemented through the procedure. A 0.035 Glidewire was then advanced into the proximal aorta. The short 6-French sheath was exchanged for a 45 cm 6-French pinnacle destination sheath with a curved tip, which was advanced up to the level of the renal arteries. The catheter tip was manipulated into the left renal artery. The curved nature of the midportion of the renal artery together with a severe stenosis made it very difficult to pass the guidewire through this area. Eventually, however, the guidewire was advanced through the stenosis and out into a branch renal artery. The Quick-Cross catheter was advanced over the wire and it was also difficult to pass the Quick-Cross catheter through the stenosis as well, but eventually this was successful. The Glidewire was exchanged for a 0.018 guidewire. The tip of the sheath was advanced to the orifice of the left renal artery, and a selective angiogram was repeated at this point due to the torque from the curve of the renal artery, we lost the wire and it was very difficult to reintroduce the wire, but after switching to a 0.035 stiff-angled Glidewire, eventually the wire was able to be advanced back into the renal artery. The Quick-Cross catheter was advanced and we went throught a couple of episodes of losing the guidewire and having to start from the beginning again, but eventually the wire was reintroduced and we were able to pass the Quick-Cross catheter through to the distal renal artery. We then exchanged to a 0.014 command wire, which was able to be advanced throught the Quick-Cross catheter, and out into a renal artery branch. Quick-Cross catheter was removed, and a 4 mm x 2 cm balloon angioplasty catheter was advanced over the wire through the area of stenosis and inflated up to 4 atmospheres of pressure for 1 minute. Balloon catheter was removed and with removing the catheter again we lost the wire. The wire was reintroduced and a repeat angiogram revealed a fairly good result with just some very minimal recurrent stenosis in the area. The nephrogram, due to the chronic renal disease, really did not improve in any significant way after the balloon angioplasty. I wanted to place a stent and it has been quite a lot of time reintroducing a catheter. The wire was again lost and we changed to an SOS catheter, which did facilitate reintroducing the wire again and we made several attempts to exchange the Glidewire for a smaller wire. Eventually, the wire was introduced and we attempted to pass a 5-mm stent, but unfortunately the wire was lost again. Several additional attempts were made, but I was never able to pass the stent catheter over the wire. Another completion arteriogram was performed, which again revealed patency of the stenotic area and no change to the nephrogram, and so the procedure was stopped at this point. The introducer sheath was exchanged for the introducer for a StarClose device and I attempted to deploy this but did not achieve hemostasis so pressure was held with a QuikClot pad for 15 mins.
The rest just explains closing and everything. Sorry this is so lengthy but I didn't want to leave anything out.
These are the codes that I came up with: 35471, 36251 and 76942,26.
Any help as well as explanation or teaching will be greatly appreciated. Thanks.