# stent placement & angioplasty



## prabha (Jan 18, 2010)

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.


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## mikereyland (Jan 18, 2010)

Yes you can bill both the angioplasty and the stent of the same vessel.  If there was a post dilation of a stent placement then you can only bill the stent.  In this case the stent will need a 59 modifier due to the Primary Mech. Thrombectomy performed.

Michael D. Reyland, CPC, CIRCC
Surgical Specialists of Georgia


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## prabha (Jan 19, 2010)

Thanks for your help


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