ttglasscock
Contributor
[*]Percutaneous balloon angioplasty Axillo-Femoral Bypass
[*]Selective Catheter placement left Axillary Artery from right Subclavian Artery via Aortic Arch
[*]Left Axillary Angiogram
[*]Right Subclavian/Axillary Artery Angiogram
[*]Right lower extremity angiography
Procedure in Detail:
We placed the patient in the procedure room and prepped and draped the right groin. After a "time out" we infiltrated with local anesthesia over the right Common Femoral Artery. We performed a retrograde puncture of the artery and placed a retrograde 6 French sheath. We injected contrast and noted that the patient had a right Axillo-Femoral bypass in place. We advanced a Simmons 2 catheter through the bypass and into the Aortic Arch. We then selected the left Subclavian Artery and advanced the catheter into the left Axillary Artery. We performed angiography and then pulled the catheter back into the proximal Subclavian Artery and repeated the angiogram. We noted that there was an arteriovenous fistula in the left arm. We noted no evidence of a left Axillo-Femoral Bypass, and no arterial stenosis. We did note a series of overlapping stents in the left Innominate Vein with some mild stenosis at the proximal stent margin. We pulled the catheter back into the proximal right Subclavian Artery and performed angiography. We noted some irregularity of the origin of the right Axillary Femoral bypass but no significant stenosis. We then performed angiography of the entire bypass. We noted two focal areas of 50% stenosis in the distal portion of the bypass that we dilated with an 8mm x 40mm balloon inflated to full effacement. We noted improvement but still some residual stenosis. Because of the nature of they bypass, we did not think it was best at this point to place a stent. We then performed angiography of the right lower extremity. We noted no evidence of any retrograde flow up the Iliac Arteries and no evidence of a Femoral to Femoral bypass. We noted a weak pulse in the left groin. We considered a direct puncture of the left Femoral Artery, but due to the complexity of the patient's case and the fact that the patient could not provide us with a good detailed history of the surgery, we felt it would be advisable to obtain a CT Angiogram first before considering any further intervention. We did consider placing a catheter though the bypass and down the Thoracic Aorta, but we did not have the appropriate catheter for this available at this time.
Complications:
none EBL: xx ml
Findings:
Abdominal Aorta and Iliac Arteries:
The Abdominal Aorta and Iliac arteries were densely calcified and surgical clips were noted that may indicate prior vascular surgery. Embolic coils are noted in the area where we would expect the left Renal Artery. A circular calcification was noted in the left upper quadrant that may be vascular in nature and warrants further investigation with a CT Angiogram.
This is what I came up with:
36216 catheterization of axillary artery
75710
37224 PTA of bypass
75710 leg angiography
Do I need another 75710 for angiography of the subclavian artery?
What am I missing?
