# Lower extremity arterial angiography procedure



## Jane5711 (Nov 15, 2016)

Can anyone help with coding?

PROCEDURES PERFORMED:                                                          
1.  Bilateral lower extremity arterial angiography with runoff.                
2.  Angioplasty of the right popliteal artery with a 5.0/40-mm balloon with    
    the suboptimal angioplasty results.                                        
3.  Stenting of the right popliteal artery with a 6.0/60-mm Armada balloon.    
4.  Angioplasty of the right anterior tibial artery with a 4.0/40-mm           
    balloon.                                                                   
5.  Angioplasty of the right peroneal artery with a 4.0/40-mm balloon and      
    2.5/120-mm balloon.                                                        
6.  Thrombolysis of the right popliteal artery and distal to it with tPA       
    thrombolysis - D1.                                                         

INDICATIONS:                                                                   
1.  Rest pain with severe arterial insufficiency of the right lower            
    extremity.                                                                 
2.  Peripheral artery disease with total occlusion of the right popliteal      
    artery.                                                                    

DESCRIPTION OF PROCEDURE: After the informed consent was obtained, the         
patient was prepped and draped in the usual sterile fashion. Lidocaine 2       
percent was used for local anesthesia in the left groin, vascular access was   
obtained in the left femoral artery, and over a guidewire, 6-French long       
angiographic sheath was placed in the left femoral artery.                     

A 5-French pigtail catheter was introduced over a guidewire into the distal    
abdominal aorta and distal abdominal aortogram with bilateral lower            
extremity arterial angiography with the runoff was performed to visualize      
both lower extremity arteries.                                                 

Then, the pigtail catheter was removed.                                        

Using a 5-French universal flush catheter and a Glidewire, the long arrow      
sheath was advanced into the right common femoral and right superficial        
femoral artery.                                                                

The first subsequent angiography of the right superficial femoral artery to    



visualize the right popliteal artery was performed.                            

Then, heparin 10,000 units were given and subsequently another 5000 units of   
heparin x2 were also given during the procedure.                               

Using angled Terumo glidewire and with the help of the Quick-Cross catheter,   
the occlusion in the right popliteal artery was crossed. The Quick-Cross       
catheter was advanced in the right peroneal artery and angiography of the      
right popliteal artery was performed which showed the patency of the mid       
distal portion of the right popliteal artery with significant lesions in the   
midportion of the right popliteal artery.                                      

Then, a 5.0/40-mm Armada balloon was advanced into the proximal portion of     
the right popliteal artery, was used to dilate the lesion at 8 atmospheres.    
The balloon was advanced further in the mid portion of the right popliteal     
artery and then distal portion of the right popliteal artery with sequential   
inflations at 8 atmospheres.                                                   

The balloon was then removed. Angiography revealed that the right popliteal    
artery is now patent with significant amount of thrombus in the right          
popliteal artery.                                                              

After the angioplasty of the right popliteal artery, in its proximal           
portion, there was a significant lesion noted without any thrombus in that     
section.                                                                       

Hence, a 6.0/60-mm Absolute Pro stent was advanced into the proximal and mid   
portion of the right popliteal artery and with the distal portion of the       
stent about 1 to 2 cm proximal to the joint space is where the stent was       
deployed. The stent catheters delivery system was removed after the            
deployment of the stent.                                                       

The 6.0/60-mm balloon was advanced to post-dilate the stent at 8 atmospheres   
with good results, but distal to the stent and in the distal portion of the    
right popliteal artery, there is still significant amount of thrombus noted.   

Over the existing wire in the right peroneal artery, a 2.5/120-mm balloon      
was advanced and was used to dilate the distal portion of the right peroneal   
artery followed by midportion of the right popliteal artery, followed by       
proximal portion of the right peroneal artery. The balloon was inflated up     
to 14 atmospheres in sequential inflations.                                    

The balloon was removed and focal 50 to 70 percent stenosis noted in the       
midportion of the right peroneal artery, but there was a significant           
thrombus in the proximal portion of the right popliteal artery.                

Hence, a 4.0/40-mm Armada balloon was reintroduced into the right peroneal     
artery in its proximal portion and was used to dilate it at 10 to 14           
atmospheres. The balloon was removed and then a Pronto catheter was inserted   


to the tibioperoneal trunk and suction thrombectomy was performed x3. Some     
improvement of this thrombus was noted in the distal portion of the right      
popliteal artery, but there was still significant amount of thrombus           
present.                                                                       

Using the help of a glide catheter, 0.014 Command wire was then used to        
cross the lesion in the right anterior _____ tibial artery.                    

A 4.0/40-mm balloon was then advanced over the guidewire into the right        
anterior tibial artery and was used to dilate the right anterior tibial        
artery at 10 atmospheres. The balloon was then removed. Then, angiographic     
images were obtained.                                                          

At this point, the right anterior tibial artery now was noted to be patent     
except for the thrombus in its proximal portion. There was a similar           
thrombus in the right peroneal artery in its proximal portion. The right       
posterior tibial artery is totally occluded with a collateral arising from     
the right superficial femoral artery supplying the distal portion of the       
right posterior tibial artery. Thus, there is a 3-vessel runoff to the right   
lower extremity, but significant thrombus noted in the right anterior tibial   
artery and right peroneal artery in its proximal portion as well as            
significant thrombus noted in the distal portion of the right popliteal        
artery.                                                                        

Hence, with the help of the Quick-Cross catheter which was advanced to the     
proximal portion of the right popliteal artery, 4 mg of tPA/Activase was       
infused directly into the right popliteal artery.                              

Then, an infusion catheter was advanced into the midportion of the right       
popliteal artery and tPA infusion was started at a dose of 1 mg per hour. At   
this point, the arterial sheath was sutured in place. The patient was          
transferred in a stable condition to the floor for further care with no        
complications.                                                                 

RESULTS:                                                                       
1.  Distal abdominal aorta: The distal abdominal aorta bifurcates into 2       
    common iliac arteries. The distal abdominal aorta is of normal size.       
2.  Common iliac arteries:                                                     
    a.  The right common iliac artery has no significant disease and           
        bifurcates into internal and external iliac arteries.                  
    b.  Left common iliac artery: Left common iliac artery has no              
        significant disease. It bifurcates into the left external iliac and    
        left internal iliac arteries.                                          
3.  Internal iliac arteries: Both right and left internal iliac arteries       
    have no significant disease.                                               
4.  External iliac arteries: Both right and left external iliac arteries       
    have no significant disease and continue on as the common femoral          
    arteries.                                                                  
5.  Common femoral arteries: Both right and left common femoral arteries       

    have no significant disease and bifurcate into superficial femoral and     
    deep femoral arteries.                                                     
6.  Deep femoral arteries: Both right and left deep femoral arteries have no   
    significant disease.                                                       
7.  Superficial femoral arteries: Both the right and left superficial          
    femoral arteries have mild disease without any high-grade focal            
    stenosis.                                                                  
8.  Popliteal arteries.                                                        
    a.  Left popliteal artery: The left popliteal artery has no significant    
        disease, it continues on behind the knee, there is an artificial       
        knee on the left side and below the knee joint, the left popliteal     
        artery trifurcates into peroneal trunk and the right anterior tibial   
        arteries.                                                              
    b.  Right popliteal artery: The right popliteal artery is totally          
        occluded in its proximal portion. There is a collateral from the       
        right superficial femoral artery supplying the distal portion of the   
        right posterior tibial artery.                                         
9.  Left trifurcation arteries.                                                
    a.  The trifurcation artery on the left side consists of the left          
        anterior tibial artery and the left peroneal trunk.                    
    b.  The left anterior artery is totally occluded in its mid distal         
        portion.                                                               
    c.  The left peroneal trunk gives rise to left peroneal artery and the     
        left posterior tibial artery. The left posterior tibial artery is      
        patent up to the ankle and the left peroneal artery is patent also     
        with mild-to-moderate diffuse disease in its distal portion. There     
        is 2-vessel runoff to the left ankle.                                  
10. Trifurcation arteries on the right side:                                   
    a.  The trifurcation arteries on the right side consists of the right      
        anterior tibial artery and right peroneal trunk, so both the right     
        anterior tibial artery and right tibioperoneal trunk have              
        significant amount of thrombus noted in them.                          
    b.  The right anterior tibial artery beyond the thrombus in its proximal   
        portion is widely patent and runs up to the ankle.                     
    c.  The right peroneal artery has a thrombus in its proximal portion and   
        mid portion has high-grade stenosis, which underwent angioplasty       
        with a residual 50 percent stenosis.                                   
    d.  The right posterior tibial artery is totally occluded in its           
        proximal to midportion, but the distal portion is filled by            
        collaterals coming from the right superficial femoral artery.          
    e.  Thus, there is a 3-vessel runoff to the right ankle, but there is      
        sluggish flow in this vessel secondary to thrombus burden in the       
        proximal portion of these vessels.                                     

IMPRESSION:                                                                    
1.  Severe peripheral artery disease with total occlusion of the right         
    popliteal artery with large amount of thrombus burden in the right         
    popliteal artery with significant thrombus still noted in the right        
    anterior tibial artery and right peroneal artery despite angioplasty and   

    suction thrombectomy as well as despite a bolus of tPA in the right        
    popliteal artery.                                                          
2.  No significant disease of the left lower extremity artery with a           
    2-vessel runoff to the ankle with a patent left posterior tibial artery    
    and left peroneal artery with the mid distal portion of left anterior      
    tibial artery occluded.                                                    
3.  Three-vessel runoff to the right ankle with significant thrombus burden    
    in the right anterior tibial artery and right peroneal artery and          
    totally occluded proximal midportion of the right posterior tibial         
    artery which is filled by collaterals in its distal portion from the       
    right superficial femoral artery.                                          
4.  Prior to the procedure, there was total occlusion of the right popliteal   
    artery.                                                                    
5.  Post procedure, after angioplasty followed by stenting of the right        
    popliteal artery, the right popliteal artery in its proximal midportion    
    is patent, but the distal portion is severely compromised with a           
    thrombus burden in it and yet there is flow to both anterior tibial and    
    posterior peroneal arteries through the thrombus itself. Infusion          
    catheter is in place in the right popliteal artery in its distal portion   
    infusing tPA.                                                              

PLAN:                                                                          
1.  The patient will be kept overnight with tPA infusion in the right          
    popliteal artery and the patient will be brought back for angiography of   
    the right popliteal artery and the distal arteries in 24 hours. Further    
    management will be based on findings at that time.                         
2.  The patient will be kept on low-dose heparin drip as well as currently     
    on infusion with tPA at 1 mg an hour for about 24 hours.          

I come up with 75716, 26, 37226 RT and 37184?
Thanks.


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## Jane5711 (Nov 17, 2016)

*Please help!*

After reviewing the report further I think the codes should be 37226rt, 37228rt, 37232rt, 75716,26
Appreciate any help at all!!!! Jim (any ideas)


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## Jim Pawloski (Nov 22, 2016)

Jane5711 said:


> After reviewing the report further I think the codes should be 37226rt, 37228rt, 37232rt, 75716,26
> Appreciate any help at all!!!! Jim (any ideas)



Hello,

I agree with your 37226-rt, 37228-rt, and 37232-rt and 75716-26-59. I would also code 37186 for the suction thrombectomy, and 37221 for the infusion of thrombolytics.

Hope that helps,
Jim


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## Jane5711 (Nov 22, 2016)

*Thank you!*

Thank you!  Happy Thanksgiving!


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