Rita Bartholomew
Guru
Please help to clarify correct coding on angiograms in this procedure:
PREOPERATIVE DIAGNOSES:
1. Atherosclerosis with intermittent claudication, right lower extremity.
2. Failing angioplasty/atherectomy, right superficial femoral artery.
POSTOPERATIVE DIAGNOSES:
1. Atherosclerosis with intermittent claudication, right lower extremity.
2. Failing angioplasty/atherectomy, right superficial femoral artery.
PROCEDURES PERFORMED: Angiogram of the aorta and right lower extremity. Stent placement, right popliteal artery; stent placement, right superficial femoral artery.
SURGEON: Xxxxxx Xxxxxxx, MD.
ANESTHESIA: Local with moderate sedation.
EBL: Minimal.
COMPLICATIONS: None.
ACCESS: 6-French sheath, left common femoral artery, retrograde.
FLUORO TIME: 15.8 minutes.
CONTRAST USED: Isovue 300, 175 mL.
CLINICAL HISTORY: This very nice 81-year-old man is status post rotational atherectomy and balloon angioplasty of the right superficial femoral artery on 9/29/2013, and recurrence with worsening claudication and ultrasound evidence of failing in both the superficial femoral and popliteal arteries. He comes for imaging of the right lower extremity with intention to treat. Due to the rapid failure within 4 months, plan will be for placement of a stent if he is a candidate.
RADIOLOGIC FINDINGS: The abdominal aorta was patent with calcific common iliac arteries bilaterally of uncertain degree of stenosis, but probably about 40%. Both internal iliac arteries were patent. Both external iliac arteries were patent. Both common femoral arteries were patent. The origin of the right superficial femoral artery and profunda femoris artery was widely patent.
On the right side, the common femoral artery was patent. The profunda femoris artery had a focal area of stenosis in 1 of the branches approximately 1 cm from its origin. The other branch was patent. The profunda branch is quite early. The superficial femoral artery then was noted to be patent for the first 10 cm, but then had an area of 70% stenosis. It was then patent for another 10 cm, and then had multifocal areas of narrowing, some of these approaching 90%. Significant collateral formation was noted. The stenosis went down and into the above-the-knee popliteal artery, which had a focal area of 90% stenosis. There was evidence of 3-vessel runoff in the proximal and midcalf. Distally, however, the posterior tibial artery was clearly the dominant runoff artery, although peroneal artery reached the distal third of the calf and anterior tibial artery reached the distal ankle mortise.
I was able to successfully perform rotational atherectomy and balloon angioplasty of the right SFA, but this was unsatisfactory result. As a result, 2 LifeStents were deployed across the SFA. One with a 60 x 100 mm stent and the other with a 6 mm x 80 mm stent. These were postdilated to the 5-mm balloon and end result was excellent. Upon completion, there was a significantly improved posterior tibial pulse.
OPERATIVE REPORT: The patient was taken to the cardiac cath lab where he was placed on the table in a dorsal recumbent position. After excellent induction with moderate sedation, the skin of the groin area was prepared and draped in a standard sterile fashion. Next, using color flow duplex ultrasound guidance, I accessed the left common femoral artery in the retrograde direction. A 5-French sheath was inserted. Three-thousand units of unfractionated heparin was then given IV. Through the sheath, I passed an Omni Flush catheter into the abdominal aorta and fashioned this in the distal abdominal aorta and pulled this down to the aortic bifurcation. An AP angiogram of the distal aorta, aortic bifurcation, and iliofemoral and pelvic runoff was obtained. Next, I selectively catheterized the right common femoral artery and serialography of the right lower extremity was performed with the tip of the catheter in the right common femoral artery. Stations were used. The findings are noted above. Next, I placed a stiff wire into the right superficial femoral artery proximally and advanced a 6-French sheath up and over the aortic bifurcation with the tip of the sheath in the proximal SFA, thus selectively catheterizing this area. A total of 70 mg/kg of unfractionated heparin was given IV. Next, I used a crossing catheter in conjunction with a 0.018-inch guidewire to negotiate across the right superficial femoral and popliteal arteries. This was exchanged for a Viper wire. I then selected a 2-mm solid crown CSI Stealth device and used this to perform rotational atherectomy upon the narrowed segments of the right common femoral artery and right popliteal artery using roadmapping technique. Low and medium speeds were used throughout the entire 25-cm length of artery to be treated. Next, a 5 mm angioplasty balloon was used to post-dilate the lesions.
Completion arteriogram showed still some areas of dissection which did not appear to be flow limiting as well as greater than 40% residual stenosis. I decided to place stents, which I was inclined to do anyway. A 6 mm x 100 mm LifeStent was first deployed distally across the popliteal artery and into the superficial femoral artery. A second LifeStent measuring 6 mm x 80 mm was deployed with 1 cm of overlap into the first stent and into the more proximal SFA. A completion arteriogram was then performed. This demonstrated significant improvement in flow in the right lower extremity through the superficial femoral artery. I accepted this result.
Next, all sheaths and guidewires were removed and a 6-French sheath was inserted into the left common femoral artery. A retrograde angiogram was performed. A MynxGrip device was used to close the puncture site in the left common femoral artery. A dry sterile dressing was then applied. There were no complications, and Mr Xxxxxx tolerated the procedure well. Sponge and needle counts following the case were noted to be correct x2.
PREOPERATIVE DIAGNOSES:
1. Atherosclerosis with intermittent claudication, right lower extremity.
2. Failing angioplasty/atherectomy, right superficial femoral artery.
POSTOPERATIVE DIAGNOSES:
1. Atherosclerosis with intermittent claudication, right lower extremity.
2. Failing angioplasty/atherectomy, right superficial femoral artery.
PROCEDURES PERFORMED: Angiogram of the aorta and right lower extremity. Stent placement, right popliteal artery; stent placement, right superficial femoral artery.
SURGEON: Xxxxxx Xxxxxxx, MD.
ANESTHESIA: Local with moderate sedation.
EBL: Minimal.
COMPLICATIONS: None.
ACCESS: 6-French sheath, left common femoral artery, retrograde.
FLUORO TIME: 15.8 minutes.
CONTRAST USED: Isovue 300, 175 mL.
CLINICAL HISTORY: This very nice 81-year-old man is status post rotational atherectomy and balloon angioplasty of the right superficial femoral artery on 9/29/2013, and recurrence with worsening claudication and ultrasound evidence of failing in both the superficial femoral and popliteal arteries. He comes for imaging of the right lower extremity with intention to treat. Due to the rapid failure within 4 months, plan will be for placement of a stent if he is a candidate.
RADIOLOGIC FINDINGS: The abdominal aorta was patent with calcific common iliac arteries bilaterally of uncertain degree of stenosis, but probably about 40%. Both internal iliac arteries were patent. Both external iliac arteries were patent. Both common femoral arteries were patent. The origin of the right superficial femoral artery and profunda femoris artery was widely patent.
On the right side, the common femoral artery was patent. The profunda femoris artery had a focal area of stenosis in 1 of the branches approximately 1 cm from its origin. The other branch was patent. The profunda branch is quite early. The superficial femoral artery then was noted to be patent for the first 10 cm, but then had an area of 70% stenosis. It was then patent for another 10 cm, and then had multifocal areas of narrowing, some of these approaching 90%. Significant collateral formation was noted. The stenosis went down and into the above-the-knee popliteal artery, which had a focal area of 90% stenosis. There was evidence of 3-vessel runoff in the proximal and midcalf. Distally, however, the posterior tibial artery was clearly the dominant runoff artery, although peroneal artery reached the distal third of the calf and anterior tibial artery reached the distal ankle mortise.
I was able to successfully perform rotational atherectomy and balloon angioplasty of the right SFA, but this was unsatisfactory result. As a result, 2 LifeStents were deployed across the SFA. One with a 60 x 100 mm stent and the other with a 6 mm x 80 mm stent. These were postdilated to the 5-mm balloon and end result was excellent. Upon completion, there was a significantly improved posterior tibial pulse.
OPERATIVE REPORT: The patient was taken to the cardiac cath lab where he was placed on the table in a dorsal recumbent position. After excellent induction with moderate sedation, the skin of the groin area was prepared and draped in a standard sterile fashion. Next, using color flow duplex ultrasound guidance, I accessed the left common femoral artery in the retrograde direction. A 5-French sheath was inserted. Three-thousand units of unfractionated heparin was then given IV. Through the sheath, I passed an Omni Flush catheter into the abdominal aorta and fashioned this in the distal abdominal aorta and pulled this down to the aortic bifurcation. An AP angiogram of the distal aorta, aortic bifurcation, and iliofemoral and pelvic runoff was obtained. Next, I selectively catheterized the right common femoral artery and serialography of the right lower extremity was performed with the tip of the catheter in the right common femoral artery. Stations were used. The findings are noted above. Next, I placed a stiff wire into the right superficial femoral artery proximally and advanced a 6-French sheath up and over the aortic bifurcation with the tip of the sheath in the proximal SFA, thus selectively catheterizing this area. A total of 70 mg/kg of unfractionated heparin was given IV. Next, I used a crossing catheter in conjunction with a 0.018-inch guidewire to negotiate across the right superficial femoral and popliteal arteries. This was exchanged for a Viper wire. I then selected a 2-mm solid crown CSI Stealth device and used this to perform rotational atherectomy upon the narrowed segments of the right common femoral artery and right popliteal artery using roadmapping technique. Low and medium speeds were used throughout the entire 25-cm length of artery to be treated. Next, a 5 mm angioplasty balloon was used to post-dilate the lesions.
Completion arteriogram showed still some areas of dissection which did not appear to be flow limiting as well as greater than 40% residual stenosis. I decided to place stents, which I was inclined to do anyway. A 6 mm x 100 mm LifeStent was first deployed distally across the popliteal artery and into the superficial femoral artery. A second LifeStent measuring 6 mm x 80 mm was deployed with 1 cm of overlap into the first stent and into the more proximal SFA. A completion arteriogram was then performed. This demonstrated significant improvement in flow in the right lower extremity through the superficial femoral artery. I accepted this result.
Next, all sheaths and guidewires were removed and a 6-French sheath was inserted into the left common femoral artery. A retrograde angiogram was performed. A MynxGrip device was used to close the puncture site in the left common femoral artery. A dry sterile dressing was then applied. There were no complications, and Mr Xxxxxx tolerated the procedure well. Sponge and needle counts following the case were noted to be correct x2.