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I need additional set of expert eyes to assist me with what I could code here in this unsuccessful lower extremity case.
INDICATIONS
Patient was referred for cardiac catheterization to assess the coronary anatomy . Indications for the procedure include: Slowly healing Herpes Zoster lesions R foot, s/p PTA R ileofemoral junction.
Interventions: Unsuccessful attempt at crossing very heavily calcified CTO R popliteal.
Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Patient was brought to the cath lab after IV hydration was begun and oral premedication was given. Patient was further sedated with fentanyl and versed. Patient was prepped and draped in the usual manner. Using the modified Seldinger access technique, a 5 French sheath was placed in the left femoral artery. A 5F LIMA catheter was used to replace the sheath with a 5F Long 45 cm sheath around the horn with its tip at the R CFA.
Initial angiography of the R leg revealed CTO R politeal artery after a 80% stenosis. Heparin IV was given. I tried crossing the CTO lesion with multiple wires, a 0.035 Glide wire, a Glide Advantage wire, a 0.018 Goldtip CTO wire and a 0.014 Pilot 150 wire with 0.018 Trailblazer and 0.035 Seeker wire with no success, due to extensive calcification of the lesion. There was extensive collateralization to the infrapopliteal vessels.
Note teat the R external. iliac and common femoral were widely patent.
At the end of the procedure, the sheath was removed and hemostasis to the left femoral was achieved using Angio-Seal.
The patient tolerated the procedure and left the catheter lab in stable condition.
Estimated Blood Loss: less than 100 mL
Specimens Collected: None
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable
Condition: stable
Moderate conscious sedation was administered by a qualified nursing professional under Continuous hemodynamic monitoring starting at 9:41 AM , and ending at 10:51 AM
Total IV Fentanyl: 100 mcg
Total IV Versed: 3 mg
Contrast: 90 cc Isovue
Air Kerma: 44 MGY
Nurse:
Impression:
Treatment:
I did not want to cavalier more aggressive crossing of the CTO and risk closing the infrapopliteal vessels. We have the option of proceeding retrograde from the R PTA percutaneously or going from the popliteal artery surgically or treat conservatively, and see how she heals. I discussed the matter with Dr. who also prefers medical therapy at this point.
ASA
Plavix, eliquis
Beta Blocker
ACE/ARB
Statins
Continue current medical therapy
Switch to PO lasix and DC in AM
INDICATIONS
Patient was referred for cardiac catheterization to assess the coronary anatomy . Indications for the procedure include: Slowly healing Herpes Zoster lesions R foot, s/p PTA R ileofemoral junction.
Interventions: Unsuccessful attempt at crossing very heavily calcified CTO R popliteal.
Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Patient was brought to the cath lab after IV hydration was begun and oral premedication was given. Patient was further sedated with fentanyl and versed. Patient was prepped and draped in the usual manner. Using the modified Seldinger access technique, a 5 French sheath was placed in the left femoral artery. A 5F LIMA catheter was used to replace the sheath with a 5F Long 45 cm sheath around the horn with its tip at the R CFA.
Initial angiography of the R leg revealed CTO R politeal artery after a 80% stenosis. Heparin IV was given. I tried crossing the CTO lesion with multiple wires, a 0.035 Glide wire, a Glide Advantage wire, a 0.018 Goldtip CTO wire and a 0.014 Pilot 150 wire with 0.018 Trailblazer and 0.035 Seeker wire with no success, due to extensive calcification of the lesion. There was extensive collateralization to the infrapopliteal vessels.
Note teat the R external. iliac and common femoral were widely patent.
At the end of the procedure, the sheath was removed and hemostasis to the left femoral was achieved using Angio-Seal.
The patient tolerated the procedure and left the catheter lab in stable condition.
Estimated Blood Loss: less than 100 mL
Specimens Collected: None
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable
Condition: stable
Moderate conscious sedation was administered by a qualified nursing professional under Continuous hemodynamic monitoring starting at 9:41 AM , and ending at 10:51 AM
Total IV Fentanyl: 100 mcg
Total IV Versed: 3 mg
Contrast: 90 cc Isovue
Air Kerma: 44 MGY
Nurse:
Impression:
| Evidence of CTO R popliteal with inability to reasonably cross it. Extensive collaterals and good flow to the infrapopliteal vessels. Occluded R ATA with patent peroneal and R PTA |
Treatment:
I did not want to cavalier more aggressive crossing of the CTO and risk closing the infrapopliteal vessels. We have the option of proceeding retrograde from the R PTA percutaneously or going from the popliteal artery surgically or treat conservatively, and see how she heals. I discussed the matter with Dr. who also prefers medical therapy at this point.
ASA
Plavix, eliquis
Beta Blocker
ACE/ARB
Statins
Continue current medical therapy
Switch to PO lasix and DC in AM