TWilliam2019
Guru
Procedure:
1. Abdominal aortagram
2. Right lower extremity Arteriogram
3. Selective third order catheter placement in right ATA via left femoral artery access
4. Ultrasound-guided percutaneous access of left common femoral artery.
5. Percutaneous angioplasty and stenting of right SFA
6. Intra-arterial thrombolysis right ATA
7. Percutaneous mechanical thrombectomy right anterior tibial artery
8. Radiologic supervision and interpretation of all of the above.
Brief history and indications for procedure: Pt with Sx of subacute on chronic ischemia of the RLE with rest pain of the right foot. Duplex showed severe flow reduction with multi-level arterial disease. Recommendation was made to proceed with arteriogram to better delineate arterial status and possibly offer revascularization options. Risks, benefits and alternatives explained and patient agreed to proceed. Informed consent obtained.
Description of procedure and findings: After informed consent, the patient was taken to the operating room and placed in the supine position. Patient was mildly sedated and monitored anesthesia care was administered. Both groins were prepped and the patient was draped in the usual sterile fashion. Left femoral arterial duplex ultrasound was performed. Under direct ultrasound guidance, percutaneous puncture of the left common femoral artery was achieved without difficulty after anesthetizing the skin and subcutaneous tissue with local anesthesia.
ULTRASONOGRAPHIC FINDINGS: The left common femoral artery is patent without significant atherosclerotic disease. Ultrasound guidance demonstrates successful cannulation of the common femoral artery and intra-luminal needle placement. Ultrasound was used to evaluate potential access sites for patency. The target vessel was then accessed under real time ultrasound guidance verifying intravascular needle entry. Images are stored in the chart.
An 0.035" stater wire was advanced through the needle. The needle was removed and exchanged for a 5 Fr sheath. The wire and dilator were removed and the 5Fr sheath was aspirated and flushed with heparinized saline. A J- wire was then advanced into the aorta under flouro guidance without difficulty. A universal flush catheter was advanced over the wire to the level of the L-1 vertebral body. The wire was removed and the catheter was aspirated and flushed with Heparinized saline. Power injection contrast aortography and pelvic arteriography was performed. .
ANGIOGRAPHIC FINDINGS: The aorta is patent with no stenosis. CIA and EIA are patent without focal HDS stenosis bilaterally. CFA PFA and proximal SFA appear patent bilaterally with occlusion of the mid and distal right SFA.
An 0.35 glide wire was then advanced through the UF catheter and the right common iliac artery was selected. The catheter was seated on the aortic bifurcation and the glide wire was manipulated into the mid CIA. The glide wire was successfully manipulated into the common femoral artery. The catheter was exchanged for a glide catheter which was advanced over the wire into the common femoral artery. Proximal RLE arteriogram was then performed.
ANGIOGRAPHIC FINDINGS: The common femoral and profunda femoris artery are patent. The SFA occludes 1-2 cm below its origin. There is reconstitution of a short segment of the mid SFA which then re-occludes.
Run-off arteriogram was performed from the CFA.
ANGIOGRAPHIC FINDINGS: Popliteal artery reconstitutes just above the knee and is patent across the knee. The PTA is patent but diffusely diseased. The peroneal artery is occluded. The ATA provides dominant run-off to the foot with mild disease in the ATA.
A Storq wire was advanced through the catheter and the catheter was removed. Pt was systemically heparinized with a weight-based dose of heparin. 5 Fr sheath exchanged for 45 cm 6 Fr Ansel sheath advanced over the bifurcation into the proximal SFA. Using a combination of wires and catheters, the SFA occlusion was eventually successfully crossed and the Storq wire was advanced into the popliteal artery. A vertebral catheter was advanced into the popliteal artery and contrast injection confirmed true luminal catheter placement in the popliteal artery. The wire was re-advanced and the catheter was removed. A 5 mm Self-expanding stent was positioned across the distal portion of the occlusion and deployed and post-dilated with a 4 mm balloon. The remainder of the occlusion was then -re-dilated with balloon angioplasty with the 4 mm balloon. F/U angiography showed recannalization of the SFA ut there appeared to be chronic thrombus in the proximal portion of the SFA. Decision made to use a covered stent to treat this segment. A 5 mm Viabahn stent was deployed from the top of the first stent to just below the origin of the PFA and post-dilated with the 4 mm balloon. F/U angiography showed excellent results with no residual stenosis and no complications in the SFA or popliteal artery. The vertebral catheter was advanced into the popliteal artery and completion run-off arteriogram was performed from the popliteal artery.
ANGIOGRAPHIC FINDINGS: PTA and peroneal artery appear similar to prior to intervention. There is a new occlusion of the proximal to mid Anterior tibial artery which appears to be embolic.
An 0.018 Wire was advanced into the popliteal artery and the ATA was selected. Wire was advanced to the foot. Angiojet Solent Dista catheter advanced into the ATA and intra-arterial thrombolysis performed under power pulse mode of the entire ATA. 4 mg TPA infused and allowed to sit for 10 minutes. Percutaneous mechanical thrombectomy of the ATA then performed under thrombectomy mode. F/U angiography showed complete resolution of the ATA occlusion with no other occlusions or complications. There was brisk flow to the foot and some flow in the micro-vasculature of the foot with mild to moderate micro-vascular disease. Pedal arch was partially intact.
Protamine administered. Sheath exchanged for standard length 6 Fr sheath.
Contrast injection through the sheath showed no access site complications. The access site was closed with an Exoseal closure device, the sheath was removed and non-occlusive pressure was held on the left femoral artery for 5 minutes per protocol. Following this, there was no bleeding or hematoma. Sterile dressing was applied.
37226 RT
37184 RT VS 37186 RT
75625 26
75710 26 59 RT
76937 26
1. Abdominal aortagram
2. Right lower extremity Arteriogram
3. Selective third order catheter placement in right ATA via left femoral artery access
4. Ultrasound-guided percutaneous access of left common femoral artery.
5. Percutaneous angioplasty and stenting of right SFA
6. Intra-arterial thrombolysis right ATA
7. Percutaneous mechanical thrombectomy right anterior tibial artery
8. Radiologic supervision and interpretation of all of the above.
Brief history and indications for procedure: Pt with Sx of subacute on chronic ischemia of the RLE with rest pain of the right foot. Duplex showed severe flow reduction with multi-level arterial disease. Recommendation was made to proceed with arteriogram to better delineate arterial status and possibly offer revascularization options. Risks, benefits and alternatives explained and patient agreed to proceed. Informed consent obtained.
Description of procedure and findings: After informed consent, the patient was taken to the operating room and placed in the supine position. Patient was mildly sedated and monitored anesthesia care was administered. Both groins were prepped and the patient was draped in the usual sterile fashion. Left femoral arterial duplex ultrasound was performed. Under direct ultrasound guidance, percutaneous puncture of the left common femoral artery was achieved without difficulty after anesthetizing the skin and subcutaneous tissue with local anesthesia.
ULTRASONOGRAPHIC FINDINGS: The left common femoral artery is patent without significant atherosclerotic disease. Ultrasound guidance demonstrates successful cannulation of the common femoral artery and intra-luminal needle placement. Ultrasound was used to evaluate potential access sites for patency. The target vessel was then accessed under real time ultrasound guidance verifying intravascular needle entry. Images are stored in the chart.
An 0.035" stater wire was advanced through the needle. The needle was removed and exchanged for a 5 Fr sheath. The wire and dilator were removed and the 5Fr sheath was aspirated and flushed with heparinized saline. A J- wire was then advanced into the aorta under flouro guidance without difficulty. A universal flush catheter was advanced over the wire to the level of the L-1 vertebral body. The wire was removed and the catheter was aspirated and flushed with Heparinized saline. Power injection contrast aortography and pelvic arteriography was performed. .
ANGIOGRAPHIC FINDINGS: The aorta is patent with no stenosis. CIA and EIA are patent without focal HDS stenosis bilaterally. CFA PFA and proximal SFA appear patent bilaterally with occlusion of the mid and distal right SFA.
An 0.35 glide wire was then advanced through the UF catheter and the right common iliac artery was selected. The catheter was seated on the aortic bifurcation and the glide wire was manipulated into the mid CIA. The glide wire was successfully manipulated into the common femoral artery. The catheter was exchanged for a glide catheter which was advanced over the wire into the common femoral artery. Proximal RLE arteriogram was then performed.
ANGIOGRAPHIC FINDINGS: The common femoral and profunda femoris artery are patent. The SFA occludes 1-2 cm below its origin. There is reconstitution of a short segment of the mid SFA which then re-occludes.
Run-off arteriogram was performed from the CFA.
ANGIOGRAPHIC FINDINGS: Popliteal artery reconstitutes just above the knee and is patent across the knee. The PTA is patent but diffusely diseased. The peroneal artery is occluded. The ATA provides dominant run-off to the foot with mild disease in the ATA.
A Storq wire was advanced through the catheter and the catheter was removed. Pt was systemically heparinized with a weight-based dose of heparin. 5 Fr sheath exchanged for 45 cm 6 Fr Ansel sheath advanced over the bifurcation into the proximal SFA. Using a combination of wires and catheters, the SFA occlusion was eventually successfully crossed and the Storq wire was advanced into the popliteal artery. A vertebral catheter was advanced into the popliteal artery and contrast injection confirmed true luminal catheter placement in the popliteal artery. The wire was re-advanced and the catheter was removed. A 5 mm Self-expanding stent was positioned across the distal portion of the occlusion and deployed and post-dilated with a 4 mm balloon. The remainder of the occlusion was then -re-dilated with balloon angioplasty with the 4 mm balloon. F/U angiography showed recannalization of the SFA ut there appeared to be chronic thrombus in the proximal portion of the SFA. Decision made to use a covered stent to treat this segment. A 5 mm Viabahn stent was deployed from the top of the first stent to just below the origin of the PFA and post-dilated with the 4 mm balloon. F/U angiography showed excellent results with no residual stenosis and no complications in the SFA or popliteal artery. The vertebral catheter was advanced into the popliteal artery and completion run-off arteriogram was performed from the popliteal artery.
ANGIOGRAPHIC FINDINGS: PTA and peroneal artery appear similar to prior to intervention. There is a new occlusion of the proximal to mid Anterior tibial artery which appears to be embolic.
An 0.018 Wire was advanced into the popliteal artery and the ATA was selected. Wire was advanced to the foot. Angiojet Solent Dista catheter advanced into the ATA and intra-arterial thrombolysis performed under power pulse mode of the entire ATA. 4 mg TPA infused and allowed to sit for 10 minutes. Percutaneous mechanical thrombectomy of the ATA then performed under thrombectomy mode. F/U angiography showed complete resolution of the ATA occlusion with no other occlusions or complications. There was brisk flow to the foot and some flow in the micro-vasculature of the foot with mild to moderate micro-vascular disease. Pedal arch was partially intact.
Protamine administered. Sheath exchanged for standard length 6 Fr sheath.
Contrast injection through the sheath showed no access site complications. The access site was closed with an Exoseal closure device, the sheath was removed and non-occlusive pressure was held on the left femoral artery for 5 minutes per protocol. Following this, there was no bleeding or hematoma. Sterile dressing was applied.
37226 RT
37184 RT VS 37186 RT
75625 26
75710 26 59 RT
76937 26