I don't even know where to begin with this one. I'm a beginner IR coder who was just kind of thrown in and expected to teach myself. I'm doing ok, but this has me lost! Any help would be greatly appreciated!
PROCEDURE:
1.Angiography of the left leg with selective left common iliac
angiography.
2.Left external iliac angiography.
3.Placement of a RIM catheter in the common femoral with
angiography of the common femoral, superficial femoral, profunda and
below-the-knee vessels.
INDICATION: Ischemic rest pain and abnormal arterial Doppler
suggestive of severe popliteal, common femoral and iliac stenosis.
Angioplasty of the popliteal, distal superficial femoral and ostial
superficial femoral.
COMPLICATIONS: None.
PROCEDURE: After informed consent, the patient was brought to the
cardiac catheterization lab where he was prepped and draped in the usual
sterile fashion. 10 mL of 1% lidocaine was infiltrated into the right
groin for local anesthesia. Via the percutaneous technique, arterial
access was obtained and a 6-French arterial sheath was placed. A RIM
catheter was advanced over a guidewire into the abdominal aorta. This was
maneuvered into the left common iliac and selective left iliac angiography
was performed. A Glidewire was then placed in the superficial femoral and
the RIM catheter was advanced into the common femoral and angiography of
the left leg was performed. This demonstrates severe restenosis of the
popliteal as well as severe in-stent restenosis in the distal superficial
femoral, as well as a 70% ostial left superficial femoral stenosis.
Decision was made to proceed with balloon angioplasty. A Rosen wire was
advanced through the RIM catheter and placed in the distal superficial
femoral. The RIM catheter was removed and the 6-French sheath was
exchanged for a 7-French 45 cm Destination sheath, which was placed in the
proximal left superficial femoral. The patient was anticoagulated with
heparin and ACTs were monitored. A Seeker catheter was advanced over the
Rosen wire into the distal popliteal and the Rosen wire was withdrawn and
a
Hi-Torque support wire was placed in the peroneal. A 4 x 40 AngioSculpt
balloon was used to angioplasty the popliteal. Several 3-minute
inflations
were performed in the severe stenosis in the popliteal. This balloon was
then utilized to balloon the distal superficial stents. An angiogram was
performed post angioplasty which demonstrated an excellent angiographic
result, with the 95% popliteal stenosis reduced to a 5% residual stenosis
and the 90% in-stent restenosis was reduced to a 10% residual stenosis.
The Seeker catheter was then advanced over the Hi-Torque support wire into
the distal popliteal and pullback gradient was performed. There was no
gradient across the areas that were ballooned in the popliteal and in the
distal superficial femoral. There was a 10 mm gradient in the mid
superficial femoral and the Hi-Torque support wire was placed in the
distal
superficial femoral and this area was ballooned with the 4 x 40
AngioSculpt. Attention was then turned to the ostial superficial femoral.
The Destination sheath was pulled back and there was a 20 mm gradient
across the ostial superficial femoral. The Hi-Torque support wire was
placed in the mid superficial femoral and the Glidewire was placed in the
profunda and the ostial SFA was ballooned with the 4 x 40 AngioSculpt
balloon. The 70% stenosis was reduced to 10% residual stenosis, and the
Seeker catheter was advanced over the Hi-Torque support wire. The
Hi-Torque support wire and the Glidewire were removed and pullback
gradient
was performed, and there was no gradient across the ostial superficial
femoral post angioplasty. A pullback was then performed from the common
femoral into the aorta and there was no gradient. The 7-French
Destination
sheath was then exchanged over a guidewire for a 7-French 11 cm sheath.
An
angiogram through the sheath demonstrates sheath insertion above the
bifurcation in the common femoral. There is mild plaque in the region of
sheath insertion. There is 100% occlusion of the right superficial
femoral
and manual pressure will be used for hemostasis. Patient tolerated the
procedure well without apparent complications.
FINDINGS: There is moderate to severe calcification of the left
common iliac with a 30% stenosis with no gradient across this stenosis.
The left external iliac has mild nonobstructive plaque. The left internal
iliac has a 60% proximal stenosis. The left common femoral has a 30%
stenosis. The profunda has a 70% proximal calcified stenosis. The left
superficial femoral has a 70% calcified stenosis pre angioplasty and
stenting. There is mild nonobstructive plaque in the proximal superficial
femoral. In the mid there is a 70% stenosis pre angioplasty and stenting,
with a diffuse 30% stenosis in the mid to distal left superficial femoral.
The stent in the distal superficial femoral into the popliteal has diffuse
in-stent restenosis up to 90%. The popliteal has a focal 95% stenosis.
The right anterior tibial is 100% occluded in its proximal to mid portion.
It gives rise to a large collateral to the posterior tibial and the distal
anterior tibial reconstitutes at the ankle via collaterals from the
posterior tibial and the dorsalis pedis. It has a 70% stenosis in the
foot. The tibioperoneal trunk has mild nonobstructive plaque. The
peroneal is 100% occluded in its proximal portion. The posterior tibial
is
100% occluded in its proximal portion but reconstitutes via collateral
from
the proximal anterior tibial.
IMPRESSION: Angioplasty of the popliteal with a 95% stenosis reduced
to a 5% residual stenosis. Angioplasty of diffuse in-stent restenosis in
the distal superficial femoral, 90% stenosis reduced to 10% residual
stenosis with no gradient across the lesion post angioplasty. A 70%
ostial
left superficial femoral stenosis with a 20 mm gradient reduced to a 10%
residual stenosis with no gradient post angioplasty. Angioplasty of the
mid superficial femoral, a 70% stenosis reduced to a 30% residual
stenosis.
RECOMMENDATIONS: Dual-antiplatelet therapy with aspirin and Plavix
and cardiovascular risk-factor modification. I did discuss in depth with
the patients wife, and will discuss also with the patient, that there is
a
very high probability of restenosis and a high probability of need for
repeat revascularization procedures.
I'm thinking 75710 to start?
PROCEDURE:
1.Angiography of the left leg with selective left common iliac
angiography.
2.Left external iliac angiography.
3.Placement of a RIM catheter in the common femoral with
angiography of the common femoral, superficial femoral, profunda and
below-the-knee vessels.
INDICATION: Ischemic rest pain and abnormal arterial Doppler
suggestive of severe popliteal, common femoral and iliac stenosis.
Angioplasty of the popliteal, distal superficial femoral and ostial
superficial femoral.
COMPLICATIONS: None.
PROCEDURE: After informed consent, the patient was brought to the
cardiac catheterization lab where he was prepped and draped in the usual
sterile fashion. 10 mL of 1% lidocaine was infiltrated into the right
groin for local anesthesia. Via the percutaneous technique, arterial
access was obtained and a 6-French arterial sheath was placed. A RIM
catheter was advanced over a guidewire into the abdominal aorta. This was
maneuvered into the left common iliac and selective left iliac angiography
was performed. A Glidewire was then placed in the superficial femoral and
the RIM catheter was advanced into the common femoral and angiography of
the left leg was performed. This demonstrates severe restenosis of the
popliteal as well as severe in-stent restenosis in the distal superficial
femoral, as well as a 70% ostial left superficial femoral stenosis.
Decision was made to proceed with balloon angioplasty. A Rosen wire was
advanced through the RIM catheter and placed in the distal superficial
femoral. The RIM catheter was removed and the 6-French sheath was
exchanged for a 7-French 45 cm Destination sheath, which was placed in the
proximal left superficial femoral. The patient was anticoagulated with
heparin and ACTs were monitored. A Seeker catheter was advanced over the
Rosen wire into the distal popliteal and the Rosen wire was withdrawn and
a
Hi-Torque support wire was placed in the peroneal. A 4 x 40 AngioSculpt
balloon was used to angioplasty the popliteal. Several 3-minute
inflations
were performed in the severe stenosis in the popliteal. This balloon was
then utilized to balloon the distal superficial stents. An angiogram was
performed post angioplasty which demonstrated an excellent angiographic
result, with the 95% popliteal stenosis reduced to a 5% residual stenosis
and the 90% in-stent restenosis was reduced to a 10% residual stenosis.
The Seeker catheter was then advanced over the Hi-Torque support wire into
the distal popliteal and pullback gradient was performed. There was no
gradient across the areas that were ballooned in the popliteal and in the
distal superficial femoral. There was a 10 mm gradient in the mid
superficial femoral and the Hi-Torque support wire was placed in the
distal
superficial femoral and this area was ballooned with the 4 x 40
AngioSculpt. Attention was then turned to the ostial superficial femoral.
The Destination sheath was pulled back and there was a 20 mm gradient
across the ostial superficial femoral. The Hi-Torque support wire was
placed in the mid superficial femoral and the Glidewire was placed in the
profunda and the ostial SFA was ballooned with the 4 x 40 AngioSculpt
balloon. The 70% stenosis was reduced to 10% residual stenosis, and the
Seeker catheter was advanced over the Hi-Torque support wire. The
Hi-Torque support wire and the Glidewire were removed and pullback
gradient
was performed, and there was no gradient across the ostial superficial
femoral post angioplasty. A pullback was then performed from the common
femoral into the aorta and there was no gradient. The 7-French
Destination
sheath was then exchanged over a guidewire for a 7-French 11 cm sheath.
An
angiogram through the sheath demonstrates sheath insertion above the
bifurcation in the common femoral. There is mild plaque in the region of
sheath insertion. There is 100% occlusion of the right superficial
femoral
and manual pressure will be used for hemostasis. Patient tolerated the
procedure well without apparent complications.
FINDINGS: There is moderate to severe calcification of the left
common iliac with a 30% stenosis with no gradient across this stenosis.
The left external iliac has mild nonobstructive plaque. The left internal
iliac has a 60% proximal stenosis. The left common femoral has a 30%
stenosis. The profunda has a 70% proximal calcified stenosis. The left
superficial femoral has a 70% calcified stenosis pre angioplasty and
stenting. There is mild nonobstructive plaque in the proximal superficial
femoral. In the mid there is a 70% stenosis pre angioplasty and stenting,
with a diffuse 30% stenosis in the mid to distal left superficial femoral.
The stent in the distal superficial femoral into the popliteal has diffuse
in-stent restenosis up to 90%. The popliteal has a focal 95% stenosis.
The right anterior tibial is 100% occluded in its proximal to mid portion.
It gives rise to a large collateral to the posterior tibial and the distal
anterior tibial reconstitutes at the ankle via collaterals from the
posterior tibial and the dorsalis pedis. It has a 70% stenosis in the
foot. The tibioperoneal trunk has mild nonobstructive plaque. The
peroneal is 100% occluded in its proximal portion. The posterior tibial
is
100% occluded in its proximal portion but reconstitutes via collateral
from
the proximal anterior tibial.
IMPRESSION: Angioplasty of the popliteal with a 95% stenosis reduced
to a 5% residual stenosis. Angioplasty of diffuse in-stent restenosis in
the distal superficial femoral, 90% stenosis reduced to 10% residual
stenosis with no gradient across the lesion post angioplasty. A 70%
ostial
left superficial femoral stenosis with a 20 mm gradient reduced to a 10%
residual stenosis with no gradient post angioplasty. Angioplasty of the
mid superficial femoral, a 70% stenosis reduced to a 30% residual
stenosis.
RECOMMENDATIONS: Dual-antiplatelet therapy with aspirin and Plavix
and cardiovascular risk-factor modification. I did discuss in depth with
the patients wife, and will discuss also with the patient, that there is
a
very high probability of restenosis and a high probability of need for
repeat revascularization procedures.
I'm thinking 75710 to start?
