suela923@aol.com
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Help please! I billed 37221, 37223 for the left side and 37221, 37223 for the right side because kissing stents were deployed in common iliacs but there was also diesase in the external iliacs on both sides so overlapping stents were done.
We didn't use one stent to cover both vessels we used separate stents that overlapped to take care of the CTO. Any thoughts??
Thanks!
Sue
Preprocedure diagnosis: Severe bilateral lower extremity lifestyle-limiting claudication
Postprocedure diagnosis: Severe bilateral lower extremity lifestyle-limiting claudication; chronic total occlusion of the left common iliac artery; severe obstructive disease of the left external iliac artery; severe obstructive disease of the right common iliac artery.
Procedure: Bilateral iliac artery angiography and right lower extremity angiography; traversal of left iliac chronic total occlusion; PTA and stent of bilateral common iliac arteries and left external iliac artery
Attending: Todd A. Wood M.D.
Access: Right common femoral artery and left common femoral artery
EBL: 60 cc
Complications: None
Patient presents on an outpatient elective basis in a fasting state. No prior angiography has been performed. She was prepped and draped in the usual sterile fashion. Access was obtained via the right common femoral artery utilizing a modified Seldinger technique. A 5-French 11 cm sheath was inserted. Over the wire a 5-French IM catheter was used to selectively engage and inject the left common iliac artery ostium. Sheath SideArm angiography was then performed visualizing the right iliac system as well as the remainder of the right lower extremity runoff. This demonstrated the following:
1. The left common iliac artery is severely diseased from the ostium to the bifurcation with the hypogastric. There is then a 95% ostial stenosis of the left hypogastric while the ostial left external iliac artery is occluded.
2. The mid through distal left external iliac artery is filled via left to left collaterals and is severely diffusely diseased.
3. The left common femoral artery is then only mildly diseased starting at the level of the inguinal ligament though there is some eccentric calcified plaque.
4. The proximal left profunda and left SFA appear to be moderately diseased but patent.
5. The right common iliac artery has a 60% calcific nodular proximal lesion followed by near occlusion of the distal vessel at the bifurcation of the external iliac and hypogastric.
6. The right hypogastric has a 90% ostial lesion but then is widely patent.
7. The right external iliac artery has a 90% ostial lesion into a short segment of moderate proximal disease before becoming relatively healthy.
8. The right common femoral artery has a small shelf of eccentric calcific disease likely less than 40% stenosed.
9. The right profunda is widely patent.
10. The right SFA has moderate diffuse disease from the proximal through mid segment followed by a short segment occlusion at the start of the abductor canal with robust bridging collaterals.
11. The right popliteal has moderate diffuse disease.
12. There is three-vessel distal right runoff with all tibial vessels widely patent.
On the basis of these findings and given the patient's symptoms it was deemed appropriate to consider endovascular intervention. It did appear that the relatively disease-free left common femoral artery offered an opportunity for a distal landing site should we be successful in traversing the left iliac CTO. This was further defined by obtaining access utilizing a micropuncture kit and then performing angiography via that micropuncture sheath. This confirmed the presence of an adequate landing zone just at the pelvic rim. We therefore attempted CTO traversal using multiple wires and support catheters. Eventually a 0.014 wire with support catheter crossed the CTO in a subintimal plane and was advanced to the level of the aortic bifurcation. An Outback reentry device was then used to successfully reenter the true lumen slightly above the left common iliac artery ostium. Parallel 0.035 wires were placed across both iliac systems and each side was dilated with a 5 mm x 4 cm Powerflex balloon. Once the reentry was confirmed in multiple views kissing 7 mm x 39 mm Genesis stents were positioned and simultaneously deployed at nominal atmospheres. The balance of the distal right common iliac into external iliac disease was then covered with an overlapping 7 mm x 60 mm Smart Nitinol self-expanding stent. This was then post dilated utilizing a 6 mm P3 balloon resulting in excellent expansion with no evidence of stent edge dissection and less than 20% residual stenosis at the most calcified point. The remainder of the left common and left external iliac were then covered with first a 7 mm x 120 mm Smart Nitinol self-expanding stent followed by a 7 mm x 20 mm stent bringing the coverage just to the top of the femoral head. This was then all post dilated with a 6 mm P3 balloon again resulting in excellent expansion with no evidence of stent edge related complications and less than 20% residual stenosis throughout. Hemostasis was then obtained at the right common femoral artery site utilizing an Exoseal device plus adjunctive manual compression. The same was attempted at the left common femoral artery access site however the Exoseal device failed to deploy appropriately and the collagen plug was left at the surface of the skin. This was then removed and manual compression held with easy reducibility of a small hematoma.
Result Impression
Successful traversal of left iliac chronic total occlusion with PTA and stent of bilateral common iliac arteries in a slightly double barrel kissing fashion and then additional PTA and stenting of bilateral external iliac arteries.
RECOMMENDATION: Patient will be recovered in the postprocedure area. Bed rest will be for 4 hours given the slight hematoma development in the left groin. She will be loaded with 60 mg __________l given her Plavix allergy and be maintained on 10 mg daily for one month. I will see her in clinical followup with plans to begin duplex monitoring in 1 to 3 months time based upon symptoms.
We didn't use one stent to cover both vessels we used separate stents that overlapped to take care of the CTO. Any thoughts??
Thanks!
Sue
Preprocedure diagnosis: Severe bilateral lower extremity lifestyle-limiting claudication
Postprocedure diagnosis: Severe bilateral lower extremity lifestyle-limiting claudication; chronic total occlusion of the left common iliac artery; severe obstructive disease of the left external iliac artery; severe obstructive disease of the right common iliac artery.
Procedure: Bilateral iliac artery angiography and right lower extremity angiography; traversal of left iliac chronic total occlusion; PTA and stent of bilateral common iliac arteries and left external iliac artery
Attending: Todd A. Wood M.D.
Access: Right common femoral artery and left common femoral artery
EBL: 60 cc
Complications: None
Patient presents on an outpatient elective basis in a fasting state. No prior angiography has been performed. She was prepped and draped in the usual sterile fashion. Access was obtained via the right common femoral artery utilizing a modified Seldinger technique. A 5-French 11 cm sheath was inserted. Over the wire a 5-French IM catheter was used to selectively engage and inject the left common iliac artery ostium. Sheath SideArm angiography was then performed visualizing the right iliac system as well as the remainder of the right lower extremity runoff. This demonstrated the following:
1. The left common iliac artery is severely diseased from the ostium to the bifurcation with the hypogastric. There is then a 95% ostial stenosis of the left hypogastric while the ostial left external iliac artery is occluded.
2. The mid through distal left external iliac artery is filled via left to left collaterals and is severely diffusely diseased.
3. The left common femoral artery is then only mildly diseased starting at the level of the inguinal ligament though there is some eccentric calcified plaque.
4. The proximal left profunda and left SFA appear to be moderately diseased but patent.
5. The right common iliac artery has a 60% calcific nodular proximal lesion followed by near occlusion of the distal vessel at the bifurcation of the external iliac and hypogastric.
6. The right hypogastric has a 90% ostial lesion but then is widely patent.
7. The right external iliac artery has a 90% ostial lesion into a short segment of moderate proximal disease before becoming relatively healthy.
8. The right common femoral artery has a small shelf of eccentric calcific disease likely less than 40% stenosed.
9. The right profunda is widely patent.
10. The right SFA has moderate diffuse disease from the proximal through mid segment followed by a short segment occlusion at the start of the abductor canal with robust bridging collaterals.
11. The right popliteal has moderate diffuse disease.
12. There is three-vessel distal right runoff with all tibial vessels widely patent.
On the basis of these findings and given the patient's symptoms it was deemed appropriate to consider endovascular intervention. It did appear that the relatively disease-free left common femoral artery offered an opportunity for a distal landing site should we be successful in traversing the left iliac CTO. This was further defined by obtaining access utilizing a micropuncture kit and then performing angiography via that micropuncture sheath. This confirmed the presence of an adequate landing zone just at the pelvic rim. We therefore attempted CTO traversal using multiple wires and support catheters. Eventually a 0.014 wire with support catheter crossed the CTO in a subintimal plane and was advanced to the level of the aortic bifurcation. An Outback reentry device was then used to successfully reenter the true lumen slightly above the left common iliac artery ostium. Parallel 0.035 wires were placed across both iliac systems and each side was dilated with a 5 mm x 4 cm Powerflex balloon. Once the reentry was confirmed in multiple views kissing 7 mm x 39 mm Genesis stents were positioned and simultaneously deployed at nominal atmospheres. The balance of the distal right common iliac into external iliac disease was then covered with an overlapping 7 mm x 60 mm Smart Nitinol self-expanding stent. This was then post dilated utilizing a 6 mm P3 balloon resulting in excellent expansion with no evidence of stent edge dissection and less than 20% residual stenosis at the most calcified point. The remainder of the left common and left external iliac were then covered with first a 7 mm x 120 mm Smart Nitinol self-expanding stent followed by a 7 mm x 20 mm stent bringing the coverage just to the top of the femoral head. This was then all post dilated with a 6 mm P3 balloon again resulting in excellent expansion with no evidence of stent edge related complications and less than 20% residual stenosis throughout. Hemostasis was then obtained at the right common femoral artery site utilizing an Exoseal device plus adjunctive manual compression. The same was attempted at the left common femoral artery access site however the Exoseal device failed to deploy appropriately and the collagen plug was left at the surface of the skin. This was then removed and manual compression held with easy reducibility of a small hematoma.
Result Impression
Successful traversal of left iliac chronic total occlusion with PTA and stent of bilateral common iliac arteries in a slightly double barrel kissing fashion and then additional PTA and stenting of bilateral external iliac arteries.
RECOMMENDATION: Patient will be recovered in the postprocedure area. Bed rest will be for 4 hours given the slight hematoma development in the left groin. She will be loaded with 60 mg __________l given her Plavix allergy and be maintained on 10 mg daily for one month. I will see her in clinical followup with plans to begin duplex monitoring in 1 to 3 months time based upon symptoms.