# Pvd/pvi



## rparikh (Apr 3, 2014)

I am not sure these are the correct codes  75625-26,75710-26,36247,36248,37224 and 37228


PROCEDURES PERFORMED: 
1. Digital subtraction angiography of the abdominal and aortoiliac 
vessels. ?75625, 75710
2. Selective iliofemoral angiography via contralateral approach. 
3. Selective right superficial femoral artery angiography via --36247
contralateral approach. 
4. Selective right anterior tibial angiography via contralateral 
approach. -36248
5. Angioplasty of proximal, mid and distal superficial femoral artery. -37224
6. Angioplasty of mid to distal right popliteal artery. --
7. Angioplasty of proximal and mid right anterior tibial artery. 37228
8. Left femoral angiography via bolus chase method. -
. 
DESCRIPTION OF PROCEDURE: 
After obtaining informed consent, the patient was brought to the cardiac 
catheterization laboratory. Both groins were prepared and draped in a 
sterile manner. Gowns, masks, caps and drapes were used to maintain 
strict sterile precautions. Intravenous Versed and fentanyl were used 
to obtain moderate level of sedation. Lidocaine 1% was used for local 
anesthesia. The left common femoral artery was localized using vascular 
ultrasound and access to the left common femoral artery was obtained 
with a micropuncture needle under ultrasound guidance. A standard 5 
French sheath was introduced into the left femoral artery using modified 
Seldinger technique. A pigtail catheter was then advanced over a wire 
and placed in the abdominal aorta. Digital subtraction angiography of 
the aortoiliac arteries was then done. The pigtail catheter was then 
exchanged over a wire for a Contra II catheter. Crossover was then done 
with this catheter using an Advantage Glidewire. Digital subtraction 
angiography of the femoral artery, popliteal artery and right leg 
vessels was then done sequentially. 
After reviewing the images, the decision was taken to intervene on the 
long segment of occlusion along the right SFA and mid to distal right 
popliteal artery and possibly the anterior tibial arteries. An 
Advantage Glidewire was introduced back and placed in the distal 
popliteal artery. The Contra II catheter was removed and then the 5 
French femoral sheath was exchanged for a 40 cm 6 French Destination 
sheath, which was placed in the distal right common femoral artery. A 
100 centimeter straight Glide catheter was now advanced over the wire 
with the hopes of advancing it into the distal popliteal artery and 
changing to an 0.018 system. However, the 0.018 wire could not 
negotiate into the SFA, probably due to significant stenosis along the 
path. Hence the 0.018 wire was removed and was removed and Super Stiff 
Amplatz wire was introduced into the right popliteal artery and through 
the Glide catheter. The straight Glide catheter was now removed. 
Angioplasty of the proximal to distal SFA was then done using a 5.0 x 
220 mm balloon with multiple inflations from 10 to 12 atmospheres. A 
4.0 x 20 mm was then used to perform angioplasty of the mid to distal 
popliteal artery. Of note, heparin was used for anticoagulation prior 
to initiation of intervention and sequential samples were obtained to 
maintain the ACT about 250 during the procedure. 
At this point, we are working with an Advantage Glidewire. During the 
angioplasty process, note was made that the Glidewire had gone into the 
right anterior tibial artery. The Glidewire was advanced into the mid 
anterior tibial artery. The balloon was now removed and a straight 
Glide catheter once again advanced into the SFA. Selective angiography 
of right SFA was then done showing good results with residual stenosis 
of 10-20% along the vessel. Attempts to advance the straight Glide 
catheter into the anterior tibial artery were unsuccessful. The 
anterior Glidewire was now removed and a PT Graphix wire was advanced 
through the Glide catheter into the anterior tibial artery. Multiple 
times a 20 mm balloon was now advanced over this wire into the anterior 
tibial artery. Angioplasty of proximal to mid anterior tibial artery 
was done with multiple inflations from 8 to 12 atmospheres. The balloon 
was then advanced into the proximal anterior tibial and selective 
injection of anterior tibial was done showing intraluminal course and 
location of the balloon. A Pilot 200 wire was now advanced through the 
balloon back into the mid anterior tibial artery. The balloon was 
exchanged for a 2.0 x 120 mm balloon. Multiple inflations of the 
balloon were done in the proximal to mid anterior tibial artery from 6 
to 12 atmospheres. Attempts to advance the Pilot wire into the distal 
anterior tibial were unsuccessful. Final angiographic images were then 
acquired after removing the balloon, showing no residual stenosis in the 
proximal or mid anterior tibial. There was 1 vessel flow established to 
the distal foot with collaterals from proximal and mid anterior tibial 
supplying reconstituted common peroneal artery. The wires and balloons 
were removed. 
The Destination sheath was then exchanged with a regular wire for a 7 
French standard sheath. A right femoral angiography with distal runoff 
was then done using bolus chase method. The femoral sheath was then 
secured in position and the patient was transferred to the recovery unit 
for subsequent sheath removal. Vitals were stable at the end of the 
procedure. 
Estimated blood loss was 20 mL. 
Fluoroscopy time was 28.8 minutes. 
Fluoroscopy dose was 213214 mGy cm2. 
Total contrast volume was 136 mL of Isovue. 
ANGIOGRAPHIC FINDINGS: 
Abdominal aorta shows moderate calcification. There is no stenosis 
noted. There is tapering of the distal aorta. The ends were branching 
into the iliac arteries. 
There was calcification of the common iliac and external and internal 
iliacs bilaterally. No stenosis was noted in the common or external 
iliacs bilaterally. The internal iliacs were occluded in the mid to 
distal segment bilaterally. 
Right femoral angiography shows normal right common femoral artery, 
which ends by branching into SFA and profunda femoral arteries. The 
right SFA showed varying stenosis from 50 degrees in the proximal 
segment involving the ostium with multiple tandem lesions varying from 
70-90% from mid to distal segments of the vessel. The right profunda 
femoris artery shows a 90% stenosis proximally and it is occluded in the 
mid segment. 
The distal right popliteal artery shows a 99% stenosis. It ends by 
giving rise to the anterior tibial and the tibioperoneal trunk. There 
is subtotal occlusion of the ostium of the anterior tibial with a total 
occlusion of the proximal anterior tibial artery. 
The tibioperoneal trunk shows chronic total occlusion distally. The 
common peroneal is seen reconstituting in the mid segments via 
collaterals. Distal supply to the leg is from the reconstituted common 
peroneal, which supplies the lateral aspect of the left foot via 
collaterals. 
Post-intervention, there was residual 20-30% stenosis in the mid and the 
proximal right SFA and there was no stenosis in the right popliteal. 
The right anterior tibial showed no residual stenosis in the proximal 
and mid segment. It was completely occluded in the distal third. 
Supply to the distal leg was again noted from the reconstituted common 
peroneal artery, which was getting collaterals from the anterior tibial. 
Left femoral angiography shows flush occlusion of the left superficial 
femoral artery. The left profunda femoral arterygives supply to the leg 
and via collaterals supplied left popliteal artery. Distal segments of 
the left SFA are noted via retrograde flow from the reconstituted 
popliteal artery. Distal supply to the left leg is again via 1 vessel, 
which is from the peroneal. The peroneal itself shows 90% stenosis 
proximally. 
CONCLUSION: 
1. Severe peripheral vascular disease with critical limb ischemia of 
both feet. 
2. Status post successful angioplasty of the right superficial femoral 
artery, distal right popliteal artery, proximal and mid right anterior 
tibial artery

Thank You


----------



## Jim Pawloski (Apr 3, 2014)

rparikh said:


> I am not sure these are the correct codes  75625-26,75710-26,36247,36248,37224 and 37228
> 
> 
> PROCEDURES PERFORMED:
> ...



I would use 75716- Bilateral extremity angio, 37224- PTA Fem-pop region, 37228 - PTA tibioperoneal region.  There is no mention of the renal arteries, so I would not bill 75625 and the catheterization codes go away when a lower extremity intervention is performed.
HTH,
Jim Pawloski, CIRCC


----------



## rparikh (Apr 8, 2014)

Even patient has contralateral 
approach can't we use cpt doe 36247 and 36248 with modifier 59

Thank You


----------



## Jim Pawloski (Apr 9, 2014)

rparikh said:


> Even patient has contralateral
> approach can't we use cpt doe 36247 and 36248 with modifier 59
> 
> Thank You



Catheterizations codes are bundled in the intervention, so no 36247 or 36248.
Jim


----------



## rparikh (Apr 18, 2014)

Thank You for your help.


----------

