# Multiple Procedures CCATH-NEED HELP ASAP



## ValdezSa (Nov 30, 2009)

Can anyone give me their oppinion on the case below!!  Here are the codes that apply so far...yes there are 14 codes so far....

37205, 37206, 37206-59, 75960 x3, 36247, 36248, 37201-59, 75896, 37184-51, 75716, 75774, 75774-59

Pt presents with an acute ischemic limb with
acute ischemic symptoms starting around 1 p.m.  He presented to
our hospital around 9:30 to 10 p.m., and I was consulted to see
him around 11 p.m.  He was brought semi emergently to the
radiology specials area for consideration of revascularization of
the left lower extremity after review by Dr. Steven Branch,
general surgeon who is on call for vascular surgery.  The patient
is clearly noted to have an ischemic limb below the level of the
inguinal ligament with pallor, paresthesia, perishing cold, pain
with loss of sensation to touch and pinprick and preserved motor
function of the lower extremity.  Muscles are tender and somewhat
swollen with mottling being noted of the skin also.  Having
discussed the risks, goals and benefits with the patient, we
elected to proceed with percutaneous revascularization of the
left lower extremity.

PROCEDURE:
1.  Abdominal aortogram with iliac runoff.
2.  Selective left common iliac angiogram.
3.  Selective contralateral left SFA angiogram and left leg
runoff.
4.  Angiojet thrombectomy [Rheolytic] of the left SFA, left
popliteal, left anterior tibial, left peroneal.
5.  Angiojet Rheolytic  thrombectomy of the left common iliac,
left external iliac and left common femoral arteries.
6.  Percutaneous angioplasty of the left common and left external
iliac.
7.  Percutaneous angioplasty of the left common femoral artery.
8.  Percutaneous angioplasty of the left superficial femoral
artery.
9.  Percutaneous angioplasty of the left tibioperoneal trunk.
10.  Percutaneous angioplasty of the left anterior tibial.
11.  Percutaneous angioplasty of the left peroneal.
12.  Aspiration thrombectomy of the left anterior tibial, left
popliteal and left peroneal arteries.
13.  Intra-arterial thrombolytic administration.
14.  Stent placement to the left common iliac and left external
iliac.
15.  Stent placement to left superficial femoral artery.
16.  Placement of thrombolytic infusion catheter in the left
anterior tibial, left popliteal and left superficial femoral
artery zone.  Infusion of thrombolytic therapy through the
UniFuse thrombolytic catheter.
17.  Intra-arterial nitroglycerin and verapamil administration.

METHOD:
Using careful micropuncture and modified Seldinger access
technique, we gained access to the right common femoral artery
and placed a 5-French catheter in the abdominal aorta, performing
an abdominal aortogram.  We then used a 5-French Motarjeme
catheter for contralateral access using an 0.35 guidewire.
 Having gained access to the contralateral left common iliac,
selective injections were then performed as noted above in the
common iliac, common femoral and superficial femoral artery as
well as further down in the left popliteal artery with left leg
runoff.  Later, percutaneous interventions were performed as
noted above.

PERCUTANEOUS INTERVENTION:
Initial views demonstrated a 100% occlusion of the left common
iliac.  Later after aspiration and Rheolytic thrombectomy, an
ulcerated 60% to 70% lesion was noted with overlying thrombus at
the junction of the left common and external iliac arteries at
the origin of the hypogastric which was laden with clot.  This
was later treated by percutaneous angioplasty and stent placement
using an 8 x _____  which was post dilated with an 8.0 balloon at
12 atmospheres.  We also performed Rheolytic  thrombectomy of the
left SFA, dilating this with both a 4 x 20 Dorado and
subsequently a 5 x 60 Opti-Pro.  We placed a 6 x 60 SMART stent
in the distal left SFA above the adductor canal over an area of
significant stenosis and ulcerated plaque.  This area was then
treated by balloon angioplasty using a 6 x 4 Cordis Opti-Pro
balloon at 12 atmospheres.  Good results were obtained of both
stented sites.  Extensive aspiration and recurrent runs using the
DVX Angiojet catheter, followed by the Spiroflex catheter was
utilized for the left iliac, common femoral and SFA systems, as
well as the Spiroflex for the tibioperoneal trunk and below-knee
circulation.  Aspiration thrombectomy using the Medtronic export
catheter was also utilized after this.  Recurrent administration
of intra-arterial verapamil and nitroglycerin was utilized.  A
total of 2 boluses of _____ was administered along with 2 boluses
of Integrilin.

At the end of the procedure, there was good inflow with a widely
patent common iliac, common femoral and SFA system.  Below the
adductor canal, however, there was extensive clot residual in the
tibioperoneal trunk at the origins of the anterior tibial and
peroneal arteries.  Both were treated with angioplasty using a
long, 2.5 x 2.10 Amphirion balloon at 12 atmospheres throughout.
 Despite angioplasty and recurrent aspiration thrombectomy as
well as tPA, there was residual clot.  We elected to treat this
using an indwelling UniFuse infusion system which was a 4-French
20 cm infusion system which was deployed in place, extending from
the distal left SFA across the popliteal and tibioperoneal trunk
into the proximal anterior tibial.  0.25 mg per hour tPA was
infused along with 500 mg per hour of heparin.  The ACT was
maintained at 200 to 250 seconds throughout the procedure.  The
patient tolerated the procedure well without obvious bleeding or
hemodynamic compromise.

FINAL SUMMARY:
1.  Initial 100% occlusion of the proximal left common iliac,
successfully treated by Rheolytic thrombectomy balloon
angioplasty and stent placement using an 8 x 60 Luminexx stent to
the distal left common iliac and left external iliac.
2.  Extensive thrombus and high-grade disease within the distal
left superficial femoral artery also treated by placement of a 6
x 60 SMART stent post dilated to 6.5 mm.
3.  Residual high-grade thrombus within the tibioperoneal trunk
and origins of the anterior tibial and peroneal residual despite
extensive Rheolytic thrombectomy, aspiration thrombectomy and
angioplasty, subsequently treated by indwelling thrombolytic
catheter and infusion therapy as noted above.

RECOMMENDATIONS:
The patient will return at 4 p.m. tomorrow for a relook angiogram
and possible recurrent intervention to the tibioperoneal trunk
and the below-knee circulation as needed.  Hopefully, a lot of
this clot will clear and the no reflow process will improve.  The
patient will no doubt, given the extensive nature of his
ischemia, be a candidate for a compartment syndrome below the
knee.  I have discussed this with the on-call general surgeon,
who was agreed kindly to provide fasciotomy as needed.  The risk,
goals, and benefits of this and findings were all explained to
patient and family.


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