# Peripheral angiogram and stent



## lcaskew1 (Jul 22, 2015)

I know that typically we can't bill a catheter placement when a peripheral angiogram is done with a SFA stent, but what if the catheter had to be removed from one leg to the other to do the stent? Here is the report. I used 37226,36247-XS, 75625-26, and 75716-26. Any help would be appreciated.

PERIPHERAL ANGIOGRAM AND STENT REPORT

PROCEDURES:  Abdominal aortography, bilateral lower extremity angiography,
left superficial femoral artery stent placement.

INDICATIONS:  A 58-year-old man with known peripheral vascular disease, post prior stent placement in left SFA and status post right femoral popliteal
bypass.  He has had worsening claudication in his left foot, now to class IV
with pain at rest.  There has been no skin breakdown.  His noninvasive Doppler
study suggested critical stenosis in the mid portion of the superficial
femoral artery on the left.  Peripheral angiography and if anatomy allows, PTA
and stent placement is planned.

ANESTHESIA:  Moderate intravenous sedation and local anesthetic.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient's right femoral region was prepped, draped and infiltrated with Xylocaine.  A 5-French sheath was placed in the right femoral artery via the modified Seldinger technique.  Attempts at advancing a Glidewire across the proximal common iliac artery were unsuccessful.  Iliac angiography was performed using an angled glide catheter, the angled Glidewire was advanced successfully into the aorta.  A pigtail catheter was advanced over that guidewire.  Abdominal aortography was performed in the PA view.  During attempts at advancing the angled Glidewire into the left leg, the pigtail catheter came back across the proximal right common iliac stenosis.  Decision was made to approach the left leg from the left femoral artery in antegrade fashion.  Through the right femoral sheath, right leg angiography with distal vessel runoff was performed in the PA view.

Attention was then given to the left femoral artery, which was prepped and
infiltrated with Xylocaine.  In antegrade fashion, the common femoral artery
was entered.  A 5-French sheath was placed.  Left leg angiography with distal
vessel runoff was performed in the PA view.

Heparin 3000 units were given intravenously.  Through the 5-French sheath, a
0.014 BMW guidewire was advanced down the left leg into the left and
positioned in the left popliteal segment.  A 4 x 18-mm Herculink Elite balloon
expandable stent was positioned in the left SFA stenosis and deployed at
maximal 13 atmospheres.  The stent delivery balloon was brought back and angiography was repeated.  There was evidence for edge dissection on the
proximal edge.  The balloon was exchanged over the guidewire for a 4 x 9-mm
Integrity bare-metal stent.  This was deployed in overlapping fashion with the
first stent at maximal 12 atmospheres.  The stent was brought back and
angiography was performed and guidewire were removed from the sheath.

Both arterial sheaths were removed and hemostasis was achieved on both sides with StarClose devices.  Patient tolerated the procedure well.  He was
transferred to his room in good condition.

RESULTS:
PRESSURES:
1.  Aorta 130/70.
2.  Right common femoral artery 130/70 (no gradient across the right common
iliac stenosis).

ABDOMINAL AORTOGRAPHY:  Performed in the PA view, the aorta has mild calcified plaque with 30% narrowing distally.  The right kidney arises low in the aorta and has dual arterial supply.  The right renal arteries are widely patent. Left renal arises higher and was not opacified.

RIGHT LEG ANGIOGRAPHY:  The common iliac artery proximally is narrowed at
least 50%.  There is no gradient across this stenosis.  The stenosis is very
tortuous and it was difficult getting a guidewire across.  Just distal to the
stenosis, the vessel is mildly aneurysmal.  The remainder of the common and
external iliac segments are without narrowing.  At the common femoral segment,
the vessel is calcified.  There is 50% narrowing.  Just distal to that, the
femoral to popliteal bypass graft arises.  The anastomosis is widely patent.
The native SFA is completely occluded.  The graft itself is widely patent with
brisk flow.  The distal anastomosis is widely patent with antegrade flow only.
 The distal SFA and popliteal segment is widely patent.  At the trifurcation,
there is 3-vessel runoff to the left foot, but the Peroneal artery peters out
at mid calf level.

LEFT LEG ANGIOGRAPHY:  The origin of the common iliac is narrowed 60%.  The
remainder is widely patent.  The segment of the external iliac that is imaged
is without narrowing.  The common femoral artery is not imaged.  The
superficial femoral artery has luminal irregularities, but no significant
stenosis proximally.  In the mid portion, there is focal 90% narrowing
proximal to and separate from the previously placed stents.  Distal to this
stenosis, there is a long stented segment that is widely patent.  Maximal
narrowing is 40% within the stent.  The distal SFA and popliteal are widely
patent including the balloon angioplasty site from 8/2014.  At the
trifurcation, all 3 vessels are patent.  The peroneal artery peters out in the
mid calf level, but the other 2 vessels reach the foot with good flow.

PTA RESULTS:  Mid left superficial femoral artery 90% narrowing reduced to 0% residual stenosis following stent placement (4 x 18-mm balloon expandable
stent overlapped proximally with a 4 x 9-mm bare-metal stent).  Flow across
the entire SFA is brisk.

CONCLUSIONS:
1.  Critical stenosis in the mid left SFA with 90% narrowing.
2.  Persistently patent stents in the more distal portion of the left SFA.
3.  Widely patent femoral-to-popliteal bypass graft on the right.
4.  Three-vessel runoff to both feet.
5.  Successful stent placement in the left SFA with 2 overlapping bare-metal
stents.


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## TWinsor (Jul 29, 2015)

Catheter placement is bundled with the intervention.  If the Rt side cath placement was used for the diagnostic angiography you could code with 36140 (common femoral artery).  I do not see documentaion of the 36247 separate from the intervention.  You will also need a 59 on the 75716.

HTH


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