Right popliteal over-the-wire embolectomy TIA

Messages
177
Location
Greer, SC
Best answers
0
Indication:
58-year-old patient who is presenting with acute ischemia of the right leg.

CTA showed thrombus in the popliteal artery and poor flow from the mid calf down

He is here for a right leg arterial thrombectomy arteriogram and indicated procedures to revascularize his leg in emergent fashion.

He has weakened neuromotor function already on presentation to the emergency room.

Preoperative diagnosis:
Right popliteal thrombus

Postoperative diagnosis:
Right popliteal thrombus
Right anterior tibial posterior tibial and peroneal thrombus from the mid calf down
Right peroneal distal disease

Procedure: ? 34203 ? 32561
1. Right SFA exposure in mid thigh
2. Right popliteal over-the-wire embolectomy
3. Selective catheterization of the right anterior tibial posterior tibial and peroneal arteries with selective embolectomy in all three vessels separately
4. Intra-arterial nitroglycerin injection
5. Arteriogram right leg
6. Intra-arterial tPA injection
7. Primary closure of right superficial femoral artery

Specimen:
Right popliteal anterior tibial posterior tibial and peroneal thrombus

Complications:
Appears to have thrombus in small blood vessels of the foot and ankle

Technique:

Patient was taken to the operating placed on the table in a supine position prepped and draped in standard fashion. A 10 cm Lundrigan incision was made over the medial thigh in the midportion and sharp dissection was carried down through subcutaneous tissue and the fascia was opened. Lateral to the sartorius muscle of the SFA was dissected out and controlled with Vesseloops proximally and distally.

Next a transverse arteriotomy was made on the SFA and good inflow was noted. Backflow was weak.

Next a V 18 wire was inserted towards distal and under fluoroscopy advanced into the distal popliteal artery.

This was followed by an over-the-wire thrombectomy catheter #4 and this was used to thrombectomized the popliteal artery successfully. Immediately much improved backflow was noted.

And arteriogram revealed good flow through the distal popliteal proximal anterior tibial proximal peroneal and proximal posterior tibial but from the mid calf down no flow was noted.

Therefore first the anterior tibial then the posterior tibial and then the peroneal were selectively cannulated with a 018 wire all the way down to the ankle and further thrombectomy occurred.

Despite the fact that significant amount of thrombus was removed from the 3 tibial vessels selectively and arteriogram only revealed flow down to the ankle but not to the foot.

The peroneal artery was also noted to have diffuse distal disease in the distal third.

All in all much improved flow was noted towards the distal part of the foot but no visualization of the actual foot Wessels was noted.

At this point tPA injection occurred as well as a nitroglycerin injection into the arterial system.

This was performed selectively in all 3 tibials as well.

Next the wires and catheters were removed and the arteriotomy was closed with an inside-out transverse fiber Prolene suture in running fashion. This repair was patent and hemostatic. Excellent flow was noted in the distal SFA.

The foot color immediately improved.

At this point the wound was copiously irrigated with antibiotic saline solution. 3 layer closure was performed with running PDS and 4 Monocryl for the skin.

Sterile dressings were applied and the patient was taken to recovery room in stable condition sponge and instrument counts were correct
 

mk2001

Guru
Messages
142
Best answers
0
Indication:
58-year-old patient who is presenting with acute ischemia of the right leg.

CTA showed thrombus in the popliteal artery and poor flow from the mid calf down

He is here for a right leg arterial thrombectomy arteriogram and indicated procedures to revascularize his leg in emergent fashion.

He has weakened neuromotor function already on presentation to the emergency room.

Preoperative diagnosis:
Right popliteal thrombus

Postoperative diagnosis:
Right popliteal thrombus
Right anterior tibial posterior tibial and peroneal thrombus from the mid calf down
Right peroneal distal disease

Procedure: ? 34203 ? 32561
1. Right SFA exposure in mid thigh
2. Right popliteal over-the-wire embolectomy
3. Selective catheterization of the right anterior tibial posterior tibial and peroneal arteries with selective embolectomy in all three vessels separately
4. Intra-arterial nitroglycerin injection
5. Arteriogram right leg
6. Intra-arterial tPA injection
7. Primary closure of right superficial femoral artery

Specimen:
Right popliteal anterior tibial posterior tibial and peroneal thrombus

Complications:
Appears to have thrombus in small blood vessels of the foot and ankle

Technique:

Patient was taken to the operating placed on the table in a supine position prepped and draped in standard fashion. A 10 cm Lundrigan incision was made over the medial thigh in the midportion and sharp dissection was carried down through subcutaneous tissue and the fascia was opened. Lateral to the sartorius muscle of the SFA was dissected out and controlled with Vesseloops proximally and distally.

Next a transverse arteriotomy was made on the SFA and good inflow was noted. Backflow was weak.

Next a V 18 wire was inserted towards distal and under fluoroscopy advanced into the distal popliteal artery.

This was followed by an over-the-wire thrombectomy catheter #4 and this was used to thrombectomized the popliteal artery successfully. Immediately much improved backflow was noted.

And arteriogram revealed good flow through the distal popliteal proximal anterior tibial proximal peroneal and proximal posterior tibial but from the mid calf down no flow was noted.

Therefore first the anterior tibial then the posterior tibial and then the peroneal were selectively cannulated with a 018 wire all the way down to the ankle and further thrombectomy occurred.

Despite the fact that significant amount of thrombus was removed from the 3 tibial vessels selectively and arteriogram only revealed flow down to the ankle but not to the foot.

The peroneal artery was also noted to have diffuse distal disease in the distal third.

All in all much improved flow was noted towards the distal part of the foot but no visualization of the actual foot Wessels was noted.

At this point tPA injection occurred as well as a nitroglycerin injection into the arterial system.

This was performed selectively in all 3 tibials as well.

Next the wires and catheters were removed and the arteriotomy was closed with an inside-out transverse fiber Prolene suture in running fashion. This repair was patent and hemostatic. Excellent flow was noted in the distal SFA.

The foot color immediately improved.

At this point the wound was copiously irrigated with antibiotic saline solution. 3 layer closure was performed with running PDS and 4 Monocryl for the skin.

Sterile dressings were applied and the patient was taken to recovery room in stable condition sponge and instrument counts were correct
I would say 37211 instead of 32561. I know that 37211 is included with a mechanical thrombectomy 37184 but it's not coming up as bundled with 34203.

Hope this helps!
 
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