# Abdominal w/ Legs Angio--Brachial Access



## jtuominen (May 21, 2009)

Hi there--

This was complicated angio case we recently had that also had an access site complication. Im wondering how others may code this case. I don't feel with the documentation a 75716 or 75710 is appropriate for an extremity angio after the abdominal angiogram. And I'm not convinced about billing another 75710 for the brachial access angio or a PTA. So far I have:

Cath placements:
36200-59
36245-59
36246

Procedures/RS&I:
37205
75960
35473
75962
75625
76937

OPERATIVE INDICATIONS: This patient is a 78-year-old female with
multiple atherosclerotic risk factors who is status post placement of
a Gore aortic endoluminal graft at an outlying hospital in 2006
secondary to a penetrating infrarenal aortic ulcer causing a
pseudoaneurysm. She presents at this time with a several-month history
of left leg claudication. Prior noninvasive studies show a resting
left-sided ABI of 0.5 decreasing to 0.35 post exercise. She has
palpable right-sided pedal pulses with a normal right-sided
ankle-brachial index.

DESCRIPTION OF TECHNIQUE: After informed consent was obtained the
patient was placed upon the imaging table and the left antecubital
region was prepped and draped in the usual sterile fashion. She was
given 1 gram of IV Ancef preoperatively. Conscious sedation was
achieved utilizing 6 mg IV Versed and 400 mcg IV fentanyl. Steven
Loff, RN, monitored the patient throughout this procedure under my
supervision. Total sedation time was 245 minutes. 38.9 minutes of
fluoro time and 150 mL of Visipaque were required. Skin directly over
the left brachial artery was locally anesthetized with 5 mL of 1%
lidocaine. Ultrasound was used to evaluate and document patency of the
left brachial artery. Under sterile ultrasound guidance a puncture was
made into the left brachial artery. A permanent copy image was
obtained for the patient's record. A micropuncture sheath was placed.
The patient was given 3000 units of intravenous heparin. Sheath
exchange was made for a 5 French sheath. An angled Glidewire and
pigtail catheter combination were directed down the aorta to the level
of the renal arteries. A standard abdominal aortogram was performed.
This clearly demonstrated occlusion of the left limb of this aortic
endograft. Wire exchange was made for a Rosen wire. A 90 cm 7 French
sheath was delivered down to the level of the proximal left limb of
the endograft. A JB-1 catheter and stiff Glidewire were used to access
this occluded left limb. This combination was directed down into the
left external iliac artery. Next, skin was locally anesthetized over
the pulseless left common femoral artery. Under the roadmap format the
left common femoral artery was percutaneously accessed using
single-wall puncture technique and an 18-gauge needle. A starter wire
was advanced up the external iliac artery and a 5 French sheath was
placed. A gooseneck snare was delivered through this sheath, snaring
the angled Glidewire to obtain through-and-through access in this
occluded left limb of the endograft. The snare was pulled up into the
thoracic aorta and an angled Glide catheter was delivered via the left
femoral sheath to the level of the renal arteries. Wire exchange was
made for a Rosen wire. Sheath exchange was made in the left groin for
a 40 cm 8 French sheath. The tip of this sheath was delivered to the
level of the renal arteries. Next, working from the brachial approach,
the right limb of the graft was selected and a wire was advanced down
the right iliac system. A 12 x 4 Opti balloon was positioned in the
right limb of the endograft at the level of the flow divider. Working
from the left groin a Palmaz 1055 Genesis XP self-expanding stent was
loaded onto an 8 mm balloon. This was then positioned at the level of
the flow divider in the occluded left limb. The stent was subsequently
deployed using a kissing balloon technique. The stent was then dilated
utilizing a 14 mm balloon again using the kissing balloon technique.
Postdeployment angiography via a pigtail catheter from the brachial
approach demonstrated persistent slow flow distally in the left limb
of the graft, and there was obvious deformity of the stent at this
level. We subsequently deployed a second Palmaz 1055 Genesis XP stent
utilizing the same technique. It was initially dilated with an 8 mm
balloon using the kissing balloon technique, and the stent was then
redilated to 14 mm. There was a previously placed self-expanding stent
in the proximal left external iliac artery overlapping with the distal
left limb of the endograft. This junction point between the
self-expanding stent and the left limb of the graft was gently dilated
with our 14 mm balloon taking care not to traumatize the external
iliac artery. Poststent deployment angiography was performed via a
retrograde injection through our left femoral sheath. This
demonstrated a widely patent left limb of the endograft but some
sluggish flow through the self-expanding stent in the proximal left
external iliac artery. We chose to angioplasty this stented portion of
the proximal left external iliac artery utilizing an 8 mm balloon.
Following this, a retrograde injection via the left femoral sheath
demonstrated excellent flow through the left limb of the endograft and
the stented portion of the proximal left external iliac artery. I
should note that the patient was rebolused with heparin throughout
this case and she received a total of 7000 units of heparin. She was
also given 1.25 mg of Inapsine. At this point a sheath exchange was
made in the left groin for a short 8 French sheath. We then attempted
to make a sheath exchange in the left brachial artery for a short 7
French sheath. Unfortunately during this maneuver we lost access to
the left brachial artery. This was immediately recognized and direct
compression was held over the left brachial artery puncture site.
Working from the left groin, the left subclavian artery was selected
utilizing an angled Glidewire-Glide catheter combination. Selective
left upper extremity angiography was performed via a hand injection
through this catheter. This demonstrated a patent left brachial artery
but with extravasation at the puncture site. The area was crossed with
the Glidewire and a 3 x 40 mm balloon was delivered to the level of
the brachial puncture. Our ACT at this point was 260. I insufflated
the balloon centered over the brachial puncture site and held
insufflation for 10 minutes. The balloon was subsequently deflated,
and an additional selective left upper extremity angiogram
demonstrated a widely patent left brachial artery with no
extravasation noted. Gentle compression was subsequently held over
this site for an additional 20 minutes without sequelae. The left arm
was secured with an armboard and an Ace wrap dressing. The left
femoral sheath was left in place. There was minimal swelling of the
left upper arm, but no discrete hematoma. She had a palpable left
radial pulse. The patient was subsequently returned to the Care Suites
area awake and alert and hemodynamically stable. We will allow the ACT
to normalize and then pull the left femoral sheath.

FINDINGS:
Abdominal aortogram: Single renal arteries are observed bilaterally. A
Gore aortic endoluminal graft is noted. The left limb of the graft is
occluded at the flow divider, and the occlusion extends down to the
level of the iliac bifurcation. A self-expanding stent overlaps with
the distal left limb of the graft, crosses the internal iliac artery,
and extends down into the proximal external iliac artery. There
appears to be significant deformity of the proximal portion of the
left limb of this endograft. The right limb of the endograft and the
bilateral external iliac and common femoral artedries are widely
patent. Following placement of two separate Palmaz 1055 Genesis XP
self-expanding stents in the left limb of the endograft, flow was
reestablished down this left limb. There was persistent sluggish flow
through the previously stented left external iliac artery. Following
angioplasty of the previously stented left external iliac artery with
an 8 mm balloon there was an excellent technical result with
normalized flow down the left iliac system.

Left upper extremity arteriogram: The initial left upper extremity
angiogram demonstrates extravasation in the distal left brachial
artery at our puncture site following loss of access. After
angioplasty at this puncture site with a 3 mm balloon and holding
insufflations for 10 minutes there was an excellent technical result.
The brachial artery is mildly chronically diseased, but there was
excellent flow down this vessel with no extravasation noted.

IMPRESSION:
1. Thrombosed left limb of a previously placed Gore aortic endograft
with reconstitution of flow at the level of the left iliac
bifurcation.
2. Successful recanalization of the left limb of this Gore endograft
utilizing deployment of two Palmaz 1055 self-expanding stents dilated
to 14 mm and with angioplasty of the previously stented proximal left
external iliac artery utilizing an 8 mm balloon.
3. Active extravasation of the distal left brachial artery at our
puncture site following loss of access. Subsequent control of this
puncture site utilizing insufflation of a 3 mm balloon for 10 minutes.
Normalized flow down this vessel with no dissection flap noted. The
patient had a palpable left radial pulse at the completion of this
procedure.
4. Following removal of the left femoral sheath in the Care Suites
area this patient had easily palpable dorsalis pedis pulses
bilaterally.


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## MLS2 (May 21, 2009)

I'm on pretty much the same page as you are with the codes that you have so far.  Have you had any luck getting the 76937 paid for procedures like these?  I know you can bill it with other cath. codes but most insurance carriers still aren't recognizing it with anything other than cvp codes.  just curious.
as for the upper extrem. arteriogram and angioplasty...i'm not sure that I would bill for it either.


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