Hello all, Can I get someones expert advice on coding this report. I have shortend it alot just to show what he did. Should I code all three Atherectomies and all three Angioplasties? The thing is, it seems he always does these together because of sub-optimal results, so I feel they are adjunctive procedures, but in this report I feel it my be warrented. PLEASE what are your thoughts?
Using an up and over catheter and an angled Glidewire
we were able to manipulate the wire and the catheter over into the
right common femoral artery. Previous aortograms were used for
anatomy. A selective right lower extremity arteriogram was performed.
This showed a patent common femoral, superficial femoral, profunda
arteries. A stent in the proximal superficial femoral artery was
patent without any evidence of narrowing. There was some narrowing in
the distal superficial femoral artery in the 50% range at the
adductor canal. The popliteal artery was then occluded just above the
knee joint. It ended in several collaterals. Recanalization of the
posterior tibial artery was seen likely several centimeters after the
origin. Also seen was reconstitution of the anterior tibial artery
several centimeters after the origin as well.
Given her critical limb ischemia we felt trying to open her occlusion
would be of her best interest. Intravenous Heparin was given.
Activated clotting times were checked. A wire followed by a catheter
was placed down into the proximal popliteal artery. A more selective
right lower extremity arteriogram was performed just to get better
visualization of the target vessel, the posterior tibial artery. We
were then able to cross the occluded popliteal artery, tibioperoneal
trunk, and proximal posterior tibial artery with a combination of an
0.035 inch Glidewire and a QuickCross catheter. The wire was removed.
Dye was injected into the QuickCross catheter to confirm intraluminal
placement of the posterior tibial artery. Several instillations of
intraarterial nitroglycerin were given to prevent vasospasm. I then
exchanged for a smaller 0.014 inch wire. A Pathway Jetstream device
was used for orbital atherectomy. The Pathway Jetstream device was
then chosen performing a percutaneous atherectomy. Several passes
were made with the blades down and then the blades up given a 3 mm.
maximal luminal gain. Completion arteriogram showed essentially no
flow or very stagnant flow through the treated artery but it did
trickle down suggesting either distal vasospasm or maybe embolic
debris. Prolonged angioplasty was then performed with a 3 mm. x 150
cm. balloon. Completion arteriogram showed the same result. More
nitroglycerin was instilled. We let a few minutes lapse and repeated
injection. It now revealed that the popliteal artery now was open
with nice inline flow into the tibioperoneal trunk and posterior
tibial artery which made it all the way down to the ankle. A small
area of extravasation was seen likely in the tibioperoneal trunk was
fairly small and did not seem concerning or to be growing rapidly.
Balloon angioplasty was then performed of the narrowing in the distal
superficial femoral artery. A 4 mm. balloon was chosen. Completion
arteriogram showed decent result throughout the entire leg without
any evidence of embolization.
Using an up and over catheter and an angled Glidewire
we were able to manipulate the wire and the catheter over into the
right common femoral artery. Previous aortograms were used for
anatomy. A selective right lower extremity arteriogram was performed.
This showed a patent common femoral, superficial femoral, profunda
arteries. A stent in the proximal superficial femoral artery was
patent without any evidence of narrowing. There was some narrowing in
the distal superficial femoral artery in the 50% range at the
adductor canal. The popliteal artery was then occluded just above the
knee joint. It ended in several collaterals. Recanalization of the
posterior tibial artery was seen likely several centimeters after the
origin. Also seen was reconstitution of the anterior tibial artery
several centimeters after the origin as well.
Given her critical limb ischemia we felt trying to open her occlusion
would be of her best interest. Intravenous Heparin was given.
Activated clotting times were checked. A wire followed by a catheter
was placed down into the proximal popliteal artery. A more selective
right lower extremity arteriogram was performed just to get better
visualization of the target vessel, the posterior tibial artery. We
were then able to cross the occluded popliteal artery, tibioperoneal
trunk, and proximal posterior tibial artery with a combination of an
0.035 inch Glidewire and a QuickCross catheter. The wire was removed.
Dye was injected into the QuickCross catheter to confirm intraluminal
placement of the posterior tibial artery. Several instillations of
intraarterial nitroglycerin were given to prevent vasospasm. I then
exchanged for a smaller 0.014 inch wire. A Pathway Jetstream device
was used for orbital atherectomy. The Pathway Jetstream device was
then chosen performing a percutaneous atherectomy. Several passes
were made with the blades down and then the blades up given a 3 mm.
maximal luminal gain. Completion arteriogram showed essentially no
flow or very stagnant flow through the treated artery but it did
trickle down suggesting either distal vasospasm or maybe embolic
debris. Prolonged angioplasty was then performed with a 3 mm. x 150
cm. balloon. Completion arteriogram showed the same result. More
nitroglycerin was instilled. We let a few minutes lapse and repeated
injection. It now revealed that the popliteal artery now was open
with nice inline flow into the tibioperoneal trunk and posterior
tibial artery which made it all the way down to the ankle. A small
area of extravasation was seen likely in the tibioperoneal trunk was
fairly small and did not seem concerning or to be growing rapidly.
Balloon angioplasty was then performed of the narrowing in the distal
superficial femoral artery. A 4 mm. balloon was chosen. Completion
arteriogram showed decent result throughout the entire leg without
any evidence of embolization.
