Rita Bartholomew
Guru
Not sure whether I can add 37228 for angioplasty in the left popliteal artery to dorsal pedal artery bypass graft. In other words, is it considered the femoropopliteal territory or the tibial/peroneal territory?
PREOPERATIVE DIAGNOSES:
1. Failing bypass, left lower extremity.
2. Intermittent claudication, right lower extremity.
POSTOPERATIVE DIAGNOSES:
1. Failing bypass, left lower extremity.
2. Intermittent claudication, right lower extremity.
PROCEDURES PERFORMED:
1. Angiogram of aorta and bilateral lower extremities.
2. Rotational atherectomy and balloon angioplasty of the native left popliteal artery (CSI Stealth 1.5 mm, and Chocolate balloon, 6 mm x 4 cm).
3. Balloon angioplasty of the left popliteal artery to dorsal pedal artery bypass graft (Chocolate balloon, 3 mm x 120 mm).
4. Duplex ultrasound-guided access, right common femoral artery.
SURGEON: Xxxx X. Xxxxx, M.D.
ANESTHESIA: Local with moderate sedation.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
FLUOROSCOPY TIME and CONTRAST DOSE: Please see the nursing notes.
RADIOLOGIC FINDINGS: The common femoral artery was difficult to palpate due to the patient's body habitus and so color flow duplex ultrasound was used. The abdominal aorta was patent with some mild tortuosity. Solitary renal arteries were present bilaterally which were both widely patent. On the right side, the common iliac artery, internal iliac artery, and external iliac artery were widely patent. The right common femoral artery and profunda femoris artery were widely patent. The proximal 20 cm of the right superficial femoral artery was widely patent. The distal-most superficial femoral artery into the right popliteal artery became extremely diseased and stenotic with near-total occlusion of approximately 99% intermittently throughout.
The right popliteal artery behind the knee appeared to reconstitute somewhat, and below the knee there was minimal flow in the popliteal artery and to the anterior tibial artery proximally and the common TP trunk. Numerous small collaterals were present.
On the left side, the common iliac, internal iliac, and external iliac arteries were widely patent. The left profunda femoris artery was widely patent, as was the proximal to distal superficial femoral artery. The above-the-knee popliteal artery then had a focal area of 99% stenosis for 1 cm, and distal to that the above-the-knee popliteal artery became diffusely narrowed. A bypass came off of the below-the-knee popliteal artery. The proximal 12 to 15 cm of this bypass graft was narrowed, and distally the bypass graft was more patent. The bypass graft was patent into the dorsal pedal artery of the foot, which was the only identifiable runoff vessel. In the calf, the anterior tibial, posterior tibial, and peroneal arteries were all completely occluded.
I was able to successfully cross the popliteal artery lesion, which was successfully treated with rotational atherectomy using a 1.5 mm CSI Stealth device at low, medium, and high speeds. This was then treated successfully with balloon angioplasty using a 6 mm x 4 cm balloon. Completion arteriogram did show some dissection of the popliteal artery which was not flow limiting, and I accepted this result.
Balloon angioplasty of the bypass graft was also performed. After initial angioplasty, there was still a focal area of narrowing approximately 12 cm from the origin of the bypass graft, and this was treated once again with balloon angioplasty. After this, the completion result was excellent. A narrowing of the more distal popliteal artery into the native common TP trunk, which was approximately 80%, was identified, but this was not treated. The common TP trunk itself also had another 70% to 80% stenosis which was also not treated, as this arterial segment led to a posterior tibial artery that was patent for approximately 3 cm and then became totally occluded, and a peroneal artery that also projected approximately 3 cm and became totally occluded.
DESCRIPTION OF PROCEDURE: The patient was taken to the cardiac catheterization lab, where she was placed on the table in a dorsal recumbent position. Her panniculus was retracted cranially. The skin of the groin areas was then prepared and draped in a standard sterile fashion. I then called a time-out for correct patient and procedural identification per Xxxxxx Hospital protocol.
Under local anesthesia, I accessed the right femoral artery using color-flow duplex ultrasound guidance due to the patient's body habitus and the difficulty in palpating her native arterial pulses. A 5-French Terumo micro-access sheath was inserted. Through this sheath, I advanced an Omniflush catheter into the abdominal aorta to the L1-L2 vertebral space, and the catheter was formed, and bubbles were removed.
An AP angiogram of the abdominal aorta was obtained. I then pulled the catheter down to the aortic bifurcation, where oblique images of the iliofemoral and pelvic runoff were obtained. Next, I performed a bolus-chase angiogram of bilateral lower extremities. Next, I selectively catheterized the left common superficial femoral artery from the right side. A total of 70 mg/kg of unfractionated heparin was administered IV. I inserted a 6-French sheath over a stiff wire up and over the aortic bifurcation and into the left superficial femoral artery, selectively catheterizing this artery.
Next, additional images were obtained of the left lower extremity. I was able to pass a ViperWire through the left popliteal artery lesion. A CSI 1.5 mm device was then selected and used to treat the left popliteal artery; low, medium, and high speeds were used. Next, I performed balloon angioplasty using a 6 mm x 4 cm angioplasty balloon. The balloon was inflated at 3 atmospheres for 2 minutes and then pulled back to the most significant lesion, where another 3 atmospheres for 2 minutes angioplasty was performed. A completion arteriogram was performed. This showed some dissection in the popliteal artery, but this was not flow limiting. I thought that the artery would remodel favorably.
Next, I selectively catheterized the left popliteal to dorsal pedal artery bypass graft, which had evidence of significant re-stricturing. A 3 mm x 12 cm Chocolate balloon was then obtained and used to angioplasty the bypass graft. Complete effacement of the balloon was noted into the popliteal artery. I then deflated the balloon and obtained a completion arteriogram. This showed a focal area of stenosis where the tip of the balloon was. I administered nitroglycerin and obtained another arteriogram, and this lesion persisted; thus, the 3 mm x 12 cm balloon was reinserted. Another balloon angioplasty was performed in this area; again 3 atmospheres for 2 minutes was used. I then deflated and removed the balloon, and the completion arteriogram was significantly improved. I accepted this result.
I then removed the long 6-French sheath and replaced it with a short 6-French sheath. Through this sheath, I then obtained additional images of the right lower extremity. The findings are as noted above. The groin was then re-prepared and re-draped, and a MynxGrip closure device was used to close the puncture site in the right groin area. Good hemostasis was noted. There was initial concern for failure of the device, although pressure had only been held for 5 minutes over the device at that time, and, after an additional 5 minutes of pressure, there was no evidence of bleeding. A dry sterile dressing was then applied. There were no complications, and Mrs. Xxxxx tolerated the procedure well. Sponge and needle counts followed the case were noted to be correct x2.
PREOPERATIVE DIAGNOSES:
1. Failing bypass, left lower extremity.
2. Intermittent claudication, right lower extremity.
POSTOPERATIVE DIAGNOSES:
1. Failing bypass, left lower extremity.
2. Intermittent claudication, right lower extremity.
PROCEDURES PERFORMED:
1. Angiogram of aorta and bilateral lower extremities.
2. Rotational atherectomy and balloon angioplasty of the native left popliteal artery (CSI Stealth 1.5 mm, and Chocolate balloon, 6 mm x 4 cm).
3. Balloon angioplasty of the left popliteal artery to dorsal pedal artery bypass graft (Chocolate balloon, 3 mm x 120 mm).
4. Duplex ultrasound-guided access, right common femoral artery.
SURGEON: Xxxx X. Xxxxx, M.D.
ANESTHESIA: Local with moderate sedation.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
FLUOROSCOPY TIME and CONTRAST DOSE: Please see the nursing notes.
RADIOLOGIC FINDINGS: The common femoral artery was difficult to palpate due to the patient's body habitus and so color flow duplex ultrasound was used. The abdominal aorta was patent with some mild tortuosity. Solitary renal arteries were present bilaterally which were both widely patent. On the right side, the common iliac artery, internal iliac artery, and external iliac artery were widely patent. The right common femoral artery and profunda femoris artery were widely patent. The proximal 20 cm of the right superficial femoral artery was widely patent. The distal-most superficial femoral artery into the right popliteal artery became extremely diseased and stenotic with near-total occlusion of approximately 99% intermittently throughout.
The right popliteal artery behind the knee appeared to reconstitute somewhat, and below the knee there was minimal flow in the popliteal artery and to the anterior tibial artery proximally and the common TP trunk. Numerous small collaterals were present.
On the left side, the common iliac, internal iliac, and external iliac arteries were widely patent. The left profunda femoris artery was widely patent, as was the proximal to distal superficial femoral artery. The above-the-knee popliteal artery then had a focal area of 99% stenosis for 1 cm, and distal to that the above-the-knee popliteal artery became diffusely narrowed. A bypass came off of the below-the-knee popliteal artery. The proximal 12 to 15 cm of this bypass graft was narrowed, and distally the bypass graft was more patent. The bypass graft was patent into the dorsal pedal artery of the foot, which was the only identifiable runoff vessel. In the calf, the anterior tibial, posterior tibial, and peroneal arteries were all completely occluded.
I was able to successfully cross the popliteal artery lesion, which was successfully treated with rotational atherectomy using a 1.5 mm CSI Stealth device at low, medium, and high speeds. This was then treated successfully with balloon angioplasty using a 6 mm x 4 cm balloon. Completion arteriogram did show some dissection of the popliteal artery which was not flow limiting, and I accepted this result.
Balloon angioplasty of the bypass graft was also performed. After initial angioplasty, there was still a focal area of narrowing approximately 12 cm from the origin of the bypass graft, and this was treated once again with balloon angioplasty. After this, the completion result was excellent. A narrowing of the more distal popliteal artery into the native common TP trunk, which was approximately 80%, was identified, but this was not treated. The common TP trunk itself also had another 70% to 80% stenosis which was also not treated, as this arterial segment led to a posterior tibial artery that was patent for approximately 3 cm and then became totally occluded, and a peroneal artery that also projected approximately 3 cm and became totally occluded.
DESCRIPTION OF PROCEDURE: The patient was taken to the cardiac catheterization lab, where she was placed on the table in a dorsal recumbent position. Her panniculus was retracted cranially. The skin of the groin areas was then prepared and draped in a standard sterile fashion. I then called a time-out for correct patient and procedural identification per Xxxxxx Hospital protocol.
Under local anesthesia, I accessed the right femoral artery using color-flow duplex ultrasound guidance due to the patient's body habitus and the difficulty in palpating her native arterial pulses. A 5-French Terumo micro-access sheath was inserted. Through this sheath, I advanced an Omniflush catheter into the abdominal aorta to the L1-L2 vertebral space, and the catheter was formed, and bubbles were removed.
An AP angiogram of the abdominal aorta was obtained. I then pulled the catheter down to the aortic bifurcation, where oblique images of the iliofemoral and pelvic runoff were obtained. Next, I performed a bolus-chase angiogram of bilateral lower extremities. Next, I selectively catheterized the left common superficial femoral artery from the right side. A total of 70 mg/kg of unfractionated heparin was administered IV. I inserted a 6-French sheath over a stiff wire up and over the aortic bifurcation and into the left superficial femoral artery, selectively catheterizing this artery.
Next, additional images were obtained of the left lower extremity. I was able to pass a ViperWire through the left popliteal artery lesion. A CSI 1.5 mm device was then selected and used to treat the left popliteal artery; low, medium, and high speeds were used. Next, I performed balloon angioplasty using a 6 mm x 4 cm angioplasty balloon. The balloon was inflated at 3 atmospheres for 2 minutes and then pulled back to the most significant lesion, where another 3 atmospheres for 2 minutes angioplasty was performed. A completion arteriogram was performed. This showed some dissection in the popliteal artery, but this was not flow limiting. I thought that the artery would remodel favorably.
Next, I selectively catheterized the left popliteal to dorsal pedal artery bypass graft, which had evidence of significant re-stricturing. A 3 mm x 12 cm Chocolate balloon was then obtained and used to angioplasty the bypass graft. Complete effacement of the balloon was noted into the popliteal artery. I then deflated the balloon and obtained a completion arteriogram. This showed a focal area of stenosis where the tip of the balloon was. I administered nitroglycerin and obtained another arteriogram, and this lesion persisted; thus, the 3 mm x 12 cm balloon was reinserted. Another balloon angioplasty was performed in this area; again 3 atmospheres for 2 minutes was used. I then deflated and removed the balloon, and the completion arteriogram was significantly improved. I accepted this result.
I then removed the long 6-French sheath and replaced it with a short 6-French sheath. Through this sheath, I then obtained additional images of the right lower extremity. The findings are as noted above. The groin was then re-prepared and re-draped, and a MynxGrip closure device was used to close the puncture site in the right groin area. Good hemostasis was noted. There was initial concern for failure of the device, although pressure had only been held for 5 minutes over the device at that time, and, after an additional 5 minutes of pressure, there was no evidence of bleeding. A dry sterile dressing was then applied. There were no complications, and Mrs. Xxxxx tolerated the procedure well. Sponge and needle counts followed the case were noted to be correct x2.