# infusion catheter placement



## shescka (Apr 20, 2015)

Please I'm not sure about this, any help will be really appreciated



PROCEDURE PERFORMED:

1. Aortoperipheral lower extremity angiogram.

2. AngioDynamics pulse spray infusion catheter placement in the right

   femoral-popliteal graft for infusion with thrombolytics therapy for

   24 hours.



PROCEDURE INDICATION:

Right leg claudication, pain at rest.



BRIEF HISTORY:

This is a 58-year-old male with a history of hypertension, diabetes,

prior peripheral lower extremity stents for peripheral vascular

disease, status post right femoral-popliteal artery bypass graft

placement in 2013, right third to fifth toe amputations previously,

who presented with complaints of pain starting from his right groin

all the way down to his right foot, for which a workup revealed

evidence of occlusion of the right femoral-popliteal bypass graft,

along with occlusion of the left SFA on ultrasound Doppler, for which

he was referred for an aortoperipheral angiogram with possible

intervention.



DESCRIPTION OF PROCEDURE IN DETAIL:

After informed consent was obtained, both groins were prepped and

draped in a sterile fashion, and under moderate sedation using 5 mL of

2 percent lidocaine, using the Mini Stick, a 4-French MS sheath was

placed in the left femoral artery and angiogram confirmed normal

sheath positioning, after which a 4-French pigtail catheter was

positioned in the infrarenal abdominal aorta, after which

aortoperipheral angiography was obtained using digital subtraction

angiography. Angiograms were obtained from the iliac bifurcations down

to the feet. We then noted occlusion of the right femoral popliteal

bypass graft (thrombotic occlusion), for which we prepared for an

intervention on this vessel. The 4-French sheath was exchanged for a 6-

French 45 cm sheath over a soft-tip (____)  wire in the left femoral

artery, after which the 4-French rim catheter was used to redirect the

wire down into the right common femoral artery. The 6-French 45 cm

sheath was advanced over the rim catheter down to the right common

femoral artery. The rim catheter was then exchanged for a 4-French

multipurpose catheter, through which an Amplatz wire was used to cross

into the femoral-popliteal bypass graft in the right thigh. The

multipurpose catheter was then advanced over the Amplatz wire down to

the popliteal artery over a V18 wire. This catheter was then removed

and exchanged over the V18 wire for an AngioDynamics pulse spray

catheter placed in the femoral-popliteal bypass graft down to the

popliteal artery. This catheter was then connected to IV thrombolytic

infusion with alteplase, which will infuse at 2 mg/hour for three

hours, followed by 1 mg per hour for the next 24 hours along with

continuous IV heparin infusion through the 6-French 45 cm sheath at

800 units/hour. The catheter and sheath were secured in place, and the

patient was transferred to the intensive care unit for close

monitoring.



ESTIMATED BLOOD LOSS:

30 mL.



ANGIOGRAPHIC FINDINGS:

1. The right external iliac artery stent is patent. No angiographic

   stenosis in the right common femoral artery. The right SFA has

   chronic total occlusion at its ostium along with thrombotic

   occlusion seen at the ostium of the right femoral-popliteal bypass

   graft. The right popliteal artery reconstitutes via collaterals

   below the knee, along with three-vessel runoff seen below the knee,

   but poor flow in these vessels at the level of the feet.

2. The left external iliac artery stent is patent. The left common

   femoral artery has no significant obstruction.

3. The left SFA has ostial chronic total occlusion which reconstitutes

   above the left knee along with three-vessel runoff seen in the left

   leg down to the feet.



POSTOPERATIVE DIAGNOSIS:

Successful placement of AngioDynamics catheter-directed thrombolysis

of the right femoral-popliteal bypass graft with 24-hour alteplase

infusion along with infusion of heparin through the intra-arterial

sheath.



PLAN OF CARE:

Monitor the patient in intensive care unit with IV nicardipine drip to

keep the patient's systolic blood pressure less than 140, along with

neuro checks in the ICU. Continue the alteplase infusion for 24 hours

along with the intra-arterial heparin.



We will reassess the flow in the right leg with an angiogram tomorrow.


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## Jim Pawloski (Apr 23, 2015)

shescka said:


> Please I'm not sure about this, any help will be really appreciated
> 
> 
> 
> ...



What I would code is 36247-rt-59, 75716-59 for the arteriogram and catheter placement. Then 37221 for the Infusion for thrombolysis, arterial, initial day.

HTH,
Jim Pawloski, CIRCC


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## j.monday7814 (Apr 23, 2015)

I think that was a mistype, Jim meant to say 37211 for the thrombolysis. everything else looks good


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