Can we code angioplasty seperately for the below mentioned case or is it included in the stent placement???
Following informed consent, the patient was placed in the supine
position and continuous physiologic monitoring was performed
throughout the examination. The patient was fully
recovered in the interventional radiology holding area under
direct, continuous monitoring.
The right groin sheath and catheter were prepped and draped in a
sterile fashion. Preprocedure antibiotics were given. A total of
8,000 units of heparin was given. Intra-arterial paparverine was
also given. Measurements of the ACT were also made during the
procedure.
The previously placed infusion catheter was removed over a guide
wire. Via the 6 Fr vascular sheath, contrast was injected and
selective left lower extremity angiography with imaging of the
foot was performed.
The length of the proximal graft to the level of the knee joint
was dilated to 3 mm. The proximal anastomosis was dilated to 4
mm. And injection of contrast demonstrated improvement in flow
within the graft. Residual areas of moderate to severe narrowing
of the proximal third of the graft was present. Residual filling
defect at the proximal anastomosis is consistent with residual
thrombus.
This residual thrombus in the proximal graft was treated with
pharmaco-mechanical thrombolysis using the Angiojet system and 10
mg TPA. TPA was administered using a power pulse technique with
10 mg given in 70 cc normal saline. The TPA was allowed to dwell
for 45 minutes to facilitate declotting of the proximal portion of
the graft. Subsequently the AngioJet device was operated in the
usual mechanical thrombectomy mode.
Subsequent angiography demonstrates improvement of flow in the
graft. Residual narrowing within the graft is present down to the
knee joint. This segment was dilated to 4 mm. The proximal
anastomosis was dilated to 5 mm.
Follow-up angiography demonstrates that good antegrade flow within
the graft is preserved. However long segment areas of moderate to
severe narrowing are present in the proximal portion of the graft.
In addition, a focal area of extravasation is present in the graft
just above the knee joint. Despite multiple attempts at
prolonged, submaximal balloon inflation to reduce extravasation at
this site, these attempts were not successful.
It was decided that percutaneous stent placement would
be performed to treat the contrast extravation from the graft.
The patient's lateral leg demonstrates swelling secondary to the
extravastion. The hematoma was not tense. A 6-mm by 40-mm
self-expanding nitinol vascular stent was placed across the
perforation. There was decreased contrast extravasation following
stent deployment.
Final contrast angiography with the tip of the catheter in the
left common femoral artery demonstrates a patent proximal
anastomosis. There is good flow within the graft. Multiple areas
of long segment moderate is diffuse narrowing are present in the
proximal graft. There is good flow across the stent in the mid
graft. There is good flow in the distal graft. The distal
anastomosis is widely patent. The left dorsalis pedis artery is
patent. There is diffuse narrowing of the dorsalis pedis artery
distally.
The patient will continue to be carefully monitored in the SICU.
FINDINGS:
Up to this point, the patient has received 25-26 mg tPA tissue
plasminogen activator (Alteplase)
The left femoral artery to dorsalis pedis artery bypass graft
composed of vein conduit was initially occluded. Antegrade flow
in the graft was restored with dilatation of the proximal graft 3
mm and then to 4 mm.
Residual filling defects (consistent with thrombus) at the
proximal anastomosis of the proximal aspect of the graft was
treated with pharmaco-mechanical thrombolysis. Following frontal
lysis there is resolution of the thrombus in the proximal graft.
At this point there is good flow within the graft. There is no
thrombus in the greater distal graft. The proximal graft was
dilated again to 4 mm. At this point it was noted that focal
areas of extraluminal contrast extravasation were noted in the
proximal graft. These areas are secondary to diffuse intrinsic
conduit disease in the proximal graft. In addition a focal area
of extravasation in the graft at the level of the knee is related
to previous balloon perforation. Extravasation at this site was
treated with deployment of a 6-mm self-expanding vascular stent.
There is improvement in extravasation following stent deployment.
There is good flow within the graft at the conclusion of the
study. The proximal and distal anastomoses are patent. There is
decreased contrast extravasation at the site of prior perforation.
Diffuse intrinsic proximal graft disease is present and graft
revision is recommended. The ossicle artery, ultrasound is pedis
artery, is patent at the conclusion of the procedure.
IMPRESSION:
Restoration of antegrade flow within the left femoral artery to
dorsalis pedis artery bypass graft following balloon angioplasty
of the length of the proximal half of the graft.
Residual thrombus in the proximal aspect of the graft treated with
pharmaco-mechanical thrombolysis using the Angiojet system.
Restoration of good antegrade flow in the distal graft with a
patent distal anastomosis. Patent left dorsalis pedis artery with
distal disease.
Severe narrowing of the conduit at the knee joint treated with
balloon angioplasty to 4mm. Balloon rupture leading to small
conduit perforation. Following discussion with the vascular
surgeon, it was decided that deployment would be performed. 6 mm
self-expanding nitinol vascular stent deployment resulting in
reduced contrast extravasation.
At the conclusion of the study, there is good flow within the
graft. Multiple focal areas of moderate to severe narrowing
present in the proximal graft.
The distal and proximal anastomoses are widely patent. There is
good flow into the left dorsalis pedis artery which demonstrates
disease distally.
Following informed consent, the patient was placed in the supine
position and continuous physiologic monitoring was performed
throughout the examination. The patient was fully
recovered in the interventional radiology holding area under
direct, continuous monitoring.
The right groin sheath and catheter were prepped and draped in a
sterile fashion. Preprocedure antibiotics were given. A total of
8,000 units of heparin was given. Intra-arterial paparverine was
also given. Measurements of the ACT were also made during the
procedure.
The previously placed infusion catheter was removed over a guide
wire. Via the 6 Fr vascular sheath, contrast was injected and
selective left lower extremity angiography with imaging of the
foot was performed.
The length of the proximal graft to the level of the knee joint
was dilated to 3 mm. The proximal anastomosis was dilated to 4
mm. And injection of contrast demonstrated improvement in flow
within the graft. Residual areas of moderate to severe narrowing
of the proximal third of the graft was present. Residual filling
defect at the proximal anastomosis is consistent with residual
thrombus.
This residual thrombus in the proximal graft was treated with
pharmaco-mechanical thrombolysis using the Angiojet system and 10
mg TPA. TPA was administered using a power pulse technique with
10 mg given in 70 cc normal saline. The TPA was allowed to dwell
for 45 minutes to facilitate declotting of the proximal portion of
the graft. Subsequently the AngioJet device was operated in the
usual mechanical thrombectomy mode.
Subsequent angiography demonstrates improvement of flow in the
graft. Residual narrowing within the graft is present down to the
knee joint. This segment was dilated to 4 mm. The proximal
anastomosis was dilated to 5 mm.
Follow-up angiography demonstrates that good antegrade flow within
the graft is preserved. However long segment areas of moderate to
severe narrowing are present in the proximal portion of the graft.
In addition, a focal area of extravasation is present in the graft
just above the knee joint. Despite multiple attempts at
prolonged, submaximal balloon inflation to reduce extravasation at
this site, these attempts were not successful.
It was decided that percutaneous stent placement would
be performed to treat the contrast extravation from the graft.
The patient's lateral leg demonstrates swelling secondary to the
extravastion. The hematoma was not tense. A 6-mm by 40-mm
self-expanding nitinol vascular stent was placed across the
perforation. There was decreased contrast extravasation following
stent deployment.
Final contrast angiography with the tip of the catheter in the
left common femoral artery demonstrates a patent proximal
anastomosis. There is good flow within the graft. Multiple areas
of long segment moderate is diffuse narrowing are present in the
proximal graft. There is good flow across the stent in the mid
graft. There is good flow in the distal graft. The distal
anastomosis is widely patent. The left dorsalis pedis artery is
patent. There is diffuse narrowing of the dorsalis pedis artery
distally.
The patient will continue to be carefully monitored in the SICU.
FINDINGS:
Up to this point, the patient has received 25-26 mg tPA tissue
plasminogen activator (Alteplase)
The left femoral artery to dorsalis pedis artery bypass graft
composed of vein conduit was initially occluded. Antegrade flow
in the graft was restored with dilatation of the proximal graft 3
mm and then to 4 mm.
Residual filling defects (consistent with thrombus) at the
proximal anastomosis of the proximal aspect of the graft was
treated with pharmaco-mechanical thrombolysis. Following frontal
lysis there is resolution of the thrombus in the proximal graft.
At this point there is good flow within the graft. There is no
thrombus in the greater distal graft. The proximal graft was
dilated again to 4 mm. At this point it was noted that focal
areas of extraluminal contrast extravasation were noted in the
proximal graft. These areas are secondary to diffuse intrinsic
conduit disease in the proximal graft. In addition a focal area
of extravasation in the graft at the level of the knee is related
to previous balloon perforation. Extravasation at this site was
treated with deployment of a 6-mm self-expanding vascular stent.
There is improvement in extravasation following stent deployment.
There is good flow within the graft at the conclusion of the
study. The proximal and distal anastomoses are patent. There is
decreased contrast extravasation at the site of prior perforation.
Diffuse intrinsic proximal graft disease is present and graft
revision is recommended. The ossicle artery, ultrasound is pedis
artery, is patent at the conclusion of the procedure.
IMPRESSION:
Restoration of antegrade flow within the left femoral artery to
dorsalis pedis artery bypass graft following balloon angioplasty
of the length of the proximal half of the graft.
Residual thrombus in the proximal aspect of the graft treated with
pharmaco-mechanical thrombolysis using the Angiojet system.
Restoration of good antegrade flow in the distal graft with a
patent distal anastomosis. Patent left dorsalis pedis artery with
distal disease.
Severe narrowing of the conduit at the knee joint treated with
balloon angioplasty to 4mm. Balloon rupture leading to small
conduit perforation. Following discussion with the vascular
surgeon, it was decided that deployment would be performed. 6 mm
self-expanding nitinol vascular stent deployment resulting in
reduced contrast extravasation.
At the conclusion of the study, there is good flow within the
graft. Multiple focal areas of moderate to severe narrowing
present in the proximal graft.
The distal and proximal anastomoses are widely patent. There is
good flow into the left dorsalis pedis artery which demonstrates
disease distally.