# TPA Infusion/Femoral angioplasty- HELP



## sslater (Feb 23, 2015)

I am not very familiar with these kind of procedures.  Any help is greatly appreciated.  Thank you.. 

So far I have   37224, 757102659, 37211?


PROCEDURE PERFORMED:  *Right common femoral angiogram and subsequent
angioplasty and placement of a fountain balloon infusion catheter with
subsequent tissue plasminogen activator infusion for thrombolysis in
the right femoral and into the femoral to peroneal trunk bypass graft*.

The patient presents with impending limb loss with severe rest
claudication and marked arterial insufficiency on the right.  Doppler
in January revealed total occlusion of the graft, the femoral to the
tibial peroneal trunk graft and also severe stenosis in the profunda,
as well as total occlusion of the old left SFA.  He had claudication
but not severe in January but becoming very severe in the last 3-4
days with, again, severe rest claudication elevation, _____
independent rubor, etc. 

A total of 34 mL of contrast was utilized.  Baseline creatinine is
1.2.  His hematocrit is 32.6.  He does have iron-deficiency anemia on
chronic Coumadin therapy.

A 6-French sheath was placed, 6 JR4 to cross over from the left
femoral and a 6/55 Raabe sheath placed.  5000 units of heparin
intraarterially was given.  25 of Demerol was given twice for his
severe leg pain.  He has severe claudication when his leg is not
dependent.  A 5.0 x 100 Boston balloon was used to try to open the
totally occluded common femoral.  There were collaterals to the
profunda, but the common femoral was totally occluded and a large
thrombus present in the distal common femoral.  We did balloon with
only slight improvement in flow and then placed a fountain catheter
and gave a 10 mg bolus of TPA and began an infusion 1 mg per minute
into the large thrombus with the fountain catheter resting in the vein
graft to the tibia peroneal trunk and back into the common femoral.

Initial angiograms revealed, again, total occlusion of the distal
common femoral with collaterals, rich collaterals, and the hypogastric
and internal iliac to the profunda.  Then the profunda gave
collaterals around the knee to the below-the-knee vessels with
subsequent limited runoff.  There was an external iliac stent noted on
the right that was widely patent.  This total occlusion was the common
over a long segment with collaterals filling the profunda.  We
ballooned across this total occlusion with a 5-0 balloon with minimal
more improvement in flow and placed a Quick-Cross and injected dye. 
We found that we were in the bypass graft distally.  We placed our
infusion catheter across this long thrombus that was present in the
distal common femoral and in the proximal portion of the vein graft,
which also occluded the profunda, but the profunda did have some
collaterals.

The infusion catheter was sutured in place, and the patient
transferred to ICU with 1 mg per minute of TPA infusing into this
large thrombus of distal common femoral that occluded both the
previously placed vein graft and the profundus as described above.


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## ccollison (Feb 23, 2015)

I agree with 37211, 37224 & 75710 26 59

C Collison CPPM, CCC


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