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Can someone please give me some guidance on coding this procedure report???
I am having a rather difficult time and am new to this!
Indications: The patient underwent coronary stenting 3 days ago complicated by the bleeding at the site of the right femoral arterial puncture, which was close to the inguinal ligament. This resulted in significant retroperitoneal bleeding, which was persistent and had to be treated by Dr. ___ using a covered stent. The patient unfortunately continued to have recurrent bleeding with 2g drop in hemoglobin daily over the past 2 days and intermittent hypotension. I obtained a CT angiogram of the abdomen and pelvis, which revealed no obvious leaks from around the stent. Given the patient's recurrent symptoms and after the patient was seen by Dr. ___, it was felt that it was best to proceed with angiography of the right external iliac and femoral arteries. The indications and risks of the procedure were explained to the patient and she agreed to proceed.
Description of Procedure: The patient was taken to the cath lab. The left groin was prepped and draped in the usual manner and was anesthetized with 1% lidocaine. A 6-french sheath was placed in the femoral artery using a modified Seldinger technique without any difficulty. Access of the right iliac artery was performed using a 6 French left internal mammary artery catheter and using a stiff angled glide wire, the left internal mammary artery catheter and the 6 French sheath were replaced with a 6 French long sheath, which was placed in the right external iliac artery proximally. Multiple angiograms of the right external iliac and common femoral as well as the femoral bifurcation were performed in multiple views and also when the patients right leg was bent and even when her body was bent forward. No leaks were noted. However, towards the end of the procedure, there was evidence of the minimal diffuse staining, medial to the vessel. However, more importantly, the covered stent appeared to be significantly smaller in size, than the external iliac and the common femoral arteries now considering that there is no spasm of these arteries. I discussed the case with Dr. ___ and we felt that slow low-level bleeding through a small endoleak of the stent graft may be responsible for the continued bleeding. we therefore felt it was best to dilate the stent using balloon angioplasty.
To perform balloon angioplasty, I treated the patient with 3000 units of heparin intra-arterially. A 7.0 x 20mm balloon was used to dilate the stent in its proximal and distal as well as mid portions up to 8 atmospheres. I then treated the stent with 8.0x40mm balloon covering the entire stent on both ends at 6 atmospheres (8.2cm). The patient did feel mild discomfort at the right groin with the balloon inflation. Final angiography revealed evidence of wide patency of the stent grafts which now approximates the size of the vessel with no evidence of dissection, thrombus, stain or leak. There was excellent flow along the vessel. The stent now approximated the size of the vessel. At the end of the procedure, the sheath was removed and replaced with a 6 French short sheath. The arteriotomy site on the left side was treated with Mynx device. Pressure was held for 20 minutes and the site was treated with no residual bleeding whatsoever. The patient tolerated the procedure well and left the catherization lab in stable condition. She was hemodynamically stable throughout the procedure.
any help would be appreciated it!!!!!!!!! Thank you!
I am having a rather difficult time and am new to this!
Indications: The patient underwent coronary stenting 3 days ago complicated by the bleeding at the site of the right femoral arterial puncture, which was close to the inguinal ligament. This resulted in significant retroperitoneal bleeding, which was persistent and had to be treated by Dr. ___ using a covered stent. The patient unfortunately continued to have recurrent bleeding with 2g drop in hemoglobin daily over the past 2 days and intermittent hypotension. I obtained a CT angiogram of the abdomen and pelvis, which revealed no obvious leaks from around the stent. Given the patient's recurrent symptoms and after the patient was seen by Dr. ___, it was felt that it was best to proceed with angiography of the right external iliac and femoral arteries. The indications and risks of the procedure were explained to the patient and she agreed to proceed.
Description of Procedure: The patient was taken to the cath lab. The left groin was prepped and draped in the usual manner and was anesthetized with 1% lidocaine. A 6-french sheath was placed in the femoral artery using a modified Seldinger technique without any difficulty. Access of the right iliac artery was performed using a 6 French left internal mammary artery catheter and using a stiff angled glide wire, the left internal mammary artery catheter and the 6 French sheath were replaced with a 6 French long sheath, which was placed in the right external iliac artery proximally. Multiple angiograms of the right external iliac and common femoral as well as the femoral bifurcation were performed in multiple views and also when the patients right leg was bent and even when her body was bent forward. No leaks were noted. However, towards the end of the procedure, there was evidence of the minimal diffuse staining, medial to the vessel. However, more importantly, the covered stent appeared to be significantly smaller in size, than the external iliac and the common femoral arteries now considering that there is no spasm of these arteries. I discussed the case with Dr. ___ and we felt that slow low-level bleeding through a small endoleak of the stent graft may be responsible for the continued bleeding. we therefore felt it was best to dilate the stent using balloon angioplasty.
To perform balloon angioplasty, I treated the patient with 3000 units of heparin intra-arterially. A 7.0 x 20mm balloon was used to dilate the stent in its proximal and distal as well as mid portions up to 8 atmospheres. I then treated the stent with 8.0x40mm balloon covering the entire stent on both ends at 6 atmospheres (8.2cm). The patient did feel mild discomfort at the right groin with the balloon inflation. Final angiography revealed evidence of wide patency of the stent grafts which now approximates the size of the vessel with no evidence of dissection, thrombus, stain or leak. There was excellent flow along the vessel. The stent now approximated the size of the vessel. At the end of the procedure, the sheath was removed and replaced with a 6 French short sheath. The arteriotomy site on the left side was treated with Mynx device. Pressure was held for 20 minutes and the site was treated with no residual bleeding whatsoever. The patient tolerated the procedure well and left the catherization lab in stable condition. She was hemodynamically stable throughout the procedure.
any help would be appreciated it!!!!!!!!! Thank you!
