suela923@aol.com
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I coded 75265-59, 75716-59,75774-59, 37228. I did not code for the catheter placement for the failed anterior tibial cannulation. My thought process was that I coded for as far as the doctor actually got and did not think I should bill for the catheter.
Any thoughts? Thanks, Sue
IR PTA TIB-PERONEAL ARTERY, UNILAT, INITIAL VESSEL
Right common femoral artery 5-French access.
Abdominal and pelvic aortogram and bilateral lower extremity arteriogram.
Third-order cannulation of the left posterior tibial, dorsalis pedis, and anterior tibial arteries.
2 mm balloon angioplasty of the left posterior tibial artery.
Indication: This is a 54-year-old male with end-stage renal disease on peritoneal dialysis and HIV who presented to the Wound Center with significant bilateral forefoot wounds. He was noted to have evidence of microvascular disease in the feet and mild arterial insufficiency on noninvasive studies. He presents today for an angiogram due to the nonhealing wounds. Informed consent was obtained.
Procedure Details: The patient was brought back to the Angiography Suite and placed in the supine position on the IR table. Bilateral groins were previously clipped and they were then prepped and draped in the usual sterile fashion. A timeout was performed. The common femoral artery on the right side was easily palpable. The femoral head was marked out with fluoroscopy. 2% plain lidocaine was injected into the skin and subcutaneous tissue overlying the artery. A small incision was made with an 11 blade and the track was dilated with hemostat. A single-wall needle puncture was used to puncture the right common femoral artery by palpation guidance. A Bentson wire was placed into the distal aorta. A 5-French 11 cm sheath was placed over the wire. A VCF catheter was placed into the proximal abdominal aorta. An aortogram was obtained through the auto injector. The catheter was then brought down to the aortic bifurcation and a bolus chase arteriogram was obtained of the bilateral lower extremities. The Bentson wire was then placed into the left external iliac artery and the VCF catheter was exchanged for a straight-tip infusion catheter. This was brought down to the level of the mid SFA. Arteriogram of the left tibial artery and pedal vessels was obtained.
No prior catheter-based studies or used studies were available prior to this intervention. The decision to intervene is based on the nonhealing nature of his foot wounds and evidence of significant arterial occlusive disease. A 5-French 90 cm sheath was then brought down over a wire to the level of the below-knee popliteal artery. The left posterior tibial artery was selected with an 014 stabilizer wire. A 2 x 100 mm balloon angioplasty was performed in the distal posterior tibial artery at the ankle and into the hindfoot. Followup imaging showed no vessel wall damage and complete patency. The left anterior tibial artery was then selected and the 014 wire and crossing catheter were used to attempt to cross an occluded dorsalis pedis artery. This failed cannulation. The long sheath was pulled back into the distal aorta and was then exchanged over a Bentson wire for the 5-French 11 cm sheath. A right leg arteriogram was obtained to better define the tibial vessels. An ACT was obtained. The ACT was 181. The patient was then moved to a stretcher and brought to the recovery unit, where the sheath was removed and manual pressure was applied. He tolerated the procedure well with no complications.
Findings:
Aortogram: Widely patent mesenteric and infrarenal aorta with no evidence of atherosclerosis. Patent single right renal artery. Two patent left renal arteries. Widely patent bilateral common, external, and internal iliac arteries.
Left leg arteriogram: Patent left common, deep, and superficial femoral arteries. Circumferential calcification is noted within the left SFA, popliteal, and all tibial arteries. Widely patent popliteal artery and tibial trifurcation. The peroneal artery is widely patent to the ankle. The left posterior tibial artery is patent to the mid calf and then becomes heavily diseased with multiple segments of near-occlusive stenosis, the worst of which is directly behind the ankle joint. The left anterior tibial artery is patent to the mid calf and then becomes heavily diseased with short segments of high-grade stenosis until it completely occludes at the ankle for a distance of 3 cm. It is reconstituted by collaterals but is heavily diseased as the dorsalis pedis artery, which eventually gives rise to the pedal arch. Digital arteries supplying the left 1st and 4th toes appear patent; however, there are no discernible digital arteries recognized in the 2nd, 3rd and possibly 5th toes.
Right leg arteriogram: Patent left common, deep, and superficial femoral arteries. Circumferential calcification is noted within the right SFA, popliteal, and all tibial arteries. Widely patent popliteal artery and tibial trifurcation. The peroneal artery is widely patent to the mid calf. The right posterior tibial artery is patent to the ankle, when it becomes heavily diseased with evidence of occlusion just distal to the ankle and the hindfoot with reconstitution. The right anterior tibial artery is patent to the distal calf, where it becomes heavily diseased in multiple segments. The dorsalis pedis artery does not fill well on angiogram and is obscured by patient motion. The right pedal arch again is not able to be visualized due to patient motion.
Result Impression
Widely patent arterial flow to the distal calf bilaterally. Circumferential calcification noted in most arteries fluoroscopically. Just proximal to the ankle, the tibial arteries become heavily diseased bilaterally with evidence of occlusion in the left distal anterior tibial artery and dorsalis pedis as well as the right posterior tibial artery at the ankle. Following balloon angioplasty of the left posterior tibial artery, there is no evidence of vessel wall damage and excellent technical success achieved. The left dorsalis pedis artery could not be cannulated.
Any thoughts? Thanks, Sue
IR PTA TIB-PERONEAL ARTERY, UNILAT, INITIAL VESSEL
Right common femoral artery 5-French access.
Abdominal and pelvic aortogram and bilateral lower extremity arteriogram.
Third-order cannulation of the left posterior tibial, dorsalis pedis, and anterior tibial arteries.
2 mm balloon angioplasty of the left posterior tibial artery.
Indication: This is a 54-year-old male with end-stage renal disease on peritoneal dialysis and HIV who presented to the Wound Center with significant bilateral forefoot wounds. He was noted to have evidence of microvascular disease in the feet and mild arterial insufficiency on noninvasive studies. He presents today for an angiogram due to the nonhealing wounds. Informed consent was obtained.
Procedure Details: The patient was brought back to the Angiography Suite and placed in the supine position on the IR table. Bilateral groins were previously clipped and they were then prepped and draped in the usual sterile fashion. A timeout was performed. The common femoral artery on the right side was easily palpable. The femoral head was marked out with fluoroscopy. 2% plain lidocaine was injected into the skin and subcutaneous tissue overlying the artery. A small incision was made with an 11 blade and the track was dilated with hemostat. A single-wall needle puncture was used to puncture the right common femoral artery by palpation guidance. A Bentson wire was placed into the distal aorta. A 5-French 11 cm sheath was placed over the wire. A VCF catheter was placed into the proximal abdominal aorta. An aortogram was obtained through the auto injector. The catheter was then brought down to the aortic bifurcation and a bolus chase arteriogram was obtained of the bilateral lower extremities. The Bentson wire was then placed into the left external iliac artery and the VCF catheter was exchanged for a straight-tip infusion catheter. This was brought down to the level of the mid SFA. Arteriogram of the left tibial artery and pedal vessels was obtained.
No prior catheter-based studies or used studies were available prior to this intervention. The decision to intervene is based on the nonhealing nature of his foot wounds and evidence of significant arterial occlusive disease. A 5-French 90 cm sheath was then brought down over a wire to the level of the below-knee popliteal artery. The left posterior tibial artery was selected with an 014 stabilizer wire. A 2 x 100 mm balloon angioplasty was performed in the distal posterior tibial artery at the ankle and into the hindfoot. Followup imaging showed no vessel wall damage and complete patency. The left anterior tibial artery was then selected and the 014 wire and crossing catheter were used to attempt to cross an occluded dorsalis pedis artery. This failed cannulation. The long sheath was pulled back into the distal aorta and was then exchanged over a Bentson wire for the 5-French 11 cm sheath. A right leg arteriogram was obtained to better define the tibial vessels. An ACT was obtained. The ACT was 181. The patient was then moved to a stretcher and brought to the recovery unit, where the sheath was removed and manual pressure was applied. He tolerated the procedure well with no complications.
Findings:
Aortogram: Widely patent mesenteric and infrarenal aorta with no evidence of atherosclerosis. Patent single right renal artery. Two patent left renal arteries. Widely patent bilateral common, external, and internal iliac arteries.
Left leg arteriogram: Patent left common, deep, and superficial femoral arteries. Circumferential calcification is noted within the left SFA, popliteal, and all tibial arteries. Widely patent popliteal artery and tibial trifurcation. The peroneal artery is widely patent to the ankle. The left posterior tibial artery is patent to the mid calf and then becomes heavily diseased with multiple segments of near-occlusive stenosis, the worst of which is directly behind the ankle joint. The left anterior tibial artery is patent to the mid calf and then becomes heavily diseased with short segments of high-grade stenosis until it completely occludes at the ankle for a distance of 3 cm. It is reconstituted by collaterals but is heavily diseased as the dorsalis pedis artery, which eventually gives rise to the pedal arch. Digital arteries supplying the left 1st and 4th toes appear patent; however, there are no discernible digital arteries recognized in the 2nd, 3rd and possibly 5th toes.
Right leg arteriogram: Patent left common, deep, and superficial femoral arteries. Circumferential calcification is noted within the right SFA, popliteal, and all tibial arteries. Widely patent popliteal artery and tibial trifurcation. The peroneal artery is widely patent to the mid calf. The right posterior tibial artery is patent to the ankle, when it becomes heavily diseased with evidence of occlusion just distal to the ankle and the hindfoot with reconstitution. The right anterior tibial artery is patent to the distal calf, where it becomes heavily diseased in multiple segments. The dorsalis pedis artery does not fill well on angiogram and is obscured by patient motion. The right pedal arch again is not able to be visualized due to patient motion.
Result Impression
Widely patent arterial flow to the distal calf bilaterally. Circumferential calcification noted in most arteries fluoroscopically. Just proximal to the ankle, the tibial arteries become heavily diseased bilaterally with evidence of occlusion in the left distal anterior tibial artery and dorsalis pedis as well as the right posterior tibial artery at the ankle. Following balloon angioplasty of the left posterior tibial artery, there is no evidence of vessel wall damage and excellent technical success achieved. The left dorsalis pedis artery could not be cannulated.