SURGEON IS TREATING A CHRONIC TOTAL OCCLUSION WITH A CROSSOVER DEVICE. SEE REPORT. I AM NOT SURE IF THIS A SEPARATE PROCEDURE THAT I SHOULD BE BILLING. I AM USING THE FOLLOWING CODES: 35474, 75962, 37205, 75960, 36247. I'M THINKING I AM MISSING SOMETHING.

Indication: severe bilateral leg claudication, left worse than right.




DETAILS OF PROCEDURE: The patient was identified on the operating room table. After induction of intravenous sedation, the groins were prepped and draped in the usual sterile fashion. Accessed the right femoral artery utilizing a mini stick kit. The #5 French sheath was placed on the right groin. Omniflush catheter placed to the level of the renal arteries. The renal arteries were patent. No significant stenosis. The aortoiliac arteries are patent without significant stenosis. There was some atherosclerotic plaquing. On the right, there was a coral reef type plaque at the origin of the profunda and superficial femoral arteries which created a significant stenosis to both. The superficial femoral artery was patent, though it was diseased. There was an occlusion at the adductor canal. There was a large collateral at the adductor canal which collateralized the popliteal artery. The popliteal artery was patent. There is primarily 3-vessel runoff, though it is very slow. The dominant vessels being the anterior tibial and posterior tibial arteries. On the left, there is a regular plaquing at the common femoral artery just above the profunda and superficial femoral artery takeoff. However, this did not cause a hemodynamically significant stenosis to the profunda or superficial femoral arteries. The superficial femoral artery had two high-grade stenosis in the mid superficial femoral artery, then it occluded just above the adductor canal. The popliteal artery was reconstituted and the peroneal anterior tibial arteries were the dominant flows into the foot. A guidewire was gotten from the right side over the top to the left. The images of the left leg were taken with a catheter in the left superficial femoral artery. I then exchanged out for a long #6 French sheath which was positioned in the superficial femoral artery and the patient was given 5000 units of heparin. I was able to then get a wire across the two mid superficial femoral artery stenosis and I angioplastied these both with a 6 x 100 balloon. After this was completed, I then used the crosser introducer to the level of the occlusion and then I used a crosser device which is an ultrasound-guided device to gain access through the occlusion into the popliteal artery. This was about a 10 cm total occlusion. After this was completed, I documented my position by injecting contrast into the popliteal artery and I proceeded to then exchange out for an Amplatz wire and then used a 4 x 100 balloon to balloon the chronic total occlusion. After this was completed, I then utilized a 6 x 170 stent across this area and then ballooned that with a 5 x 100 balloon. The proximal superficial femoral artery had been ballooned with a 5 x 100 balloon as well. I then did a completion study and there was good flow through the superficial femoral artery and continuous flow down across the popliteal artery and then there now appeared to be 3-vessel runoff where before there was only 2-vessel runoff. There was significant improvement in flow. The sheaths and wires were then removed and a #6 French sheath was placed in the right groin. The patient's heparin was reversed with protamine. I did not want to use an Angio-Seal device on the right groin because I most likely would be operating on that groin in the future because of the nature of the occlusion of that right common femoral artery. The patient tolerated the procedure well.




IMPRESSION:




1. NO SIGNIFICANT AORTOILIAC OR RENAL STENOSIS.

2. ON THE RIGHT, SEVERE STENOSIS OF THE DISTAL COMMON FEMORAL ARTERY WITH A CORAL REEF TYPE PLAQUE. OCCLUSION OF THE RIGHT SUPERFICIAL FEMORAL ARTERY, RECONSTITUTION OF THE POPLITEAL ARTERY WITH GOOD RUNOFF.

3. ON THE LEFT, CORAL REEF PLAQUE OF THE COMMON FEMORAL ARTERY, THOUGH NOT AS HEMODYNAMICALLY SIGNIFICANT AS ON THE RIGHT SIDE. THERE WERE TWO STENOSES IN THE SUPERFICIAL FEMORAL ARTERY WHICH WERE TREATED WITH ANGIOPLASTY AND STENT TECHNIQUES AND THEN THE CHRONIC TOTAL OCCLUSION WAS CROSSED WITH A CROSSER DEVICE AND THEN TREATED WITH A 6 X 170 STENT AND A 5 X 100 BALLOON. THE PATIENT TOLERATED THIS WELL AND HAD CONTINUOUS FLOW DOWN TO HIS FOOT AT THE END OF THE PROCEDURE.

APPRECIATE ANY ADVICE.

THANKS
VKRATZER























Dictated by Todd M Stefan, MD