suela923@aol.com
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Hello! Can we bill for add'l after basic? 75710, 75774. 36216 according to Dr. Z. "use code 75774 if addl selective cath placement and injection after the basic exam is performed. Remember a "COMPLETE" upper extremity angiogram but be done first. To me, it appears that doctor states he engaged innominate and did angiogram and gave findings and then continued on to axillary artery for the REMAINER f the upper extremity.
What do you think???? thanks!!
Procedure date: 7/9/14
Preprocedure diagnosis: Critical limb ischemia right upper extremity
Post procedure diagnosis: Critical limb ischemia right upper extremity; ostial right innominate high-grade stenosis; patent proximal right subclavian and stent; right brachial artery chronic total occlusion; high-grade restenosis of the proximal left common femoral artery just proximal to fem-fem bypass proximal graft anastomosis
Procedure: Right SideArm angiography of the left common femoral; right upper extremity selective angiography
Access: Left common femoral artery
EBL: 10 cc
Complications: None
Patient presents on outpatient basis secondary to resting right upper extremity discomfort. She was prepped and draped in usual sterile fashion. Access was obtained via the left common femoral artery utilizing a 5-French micropuncture kit. A significant degree of scar tissue was encountered in this process. Sequential dilation was required just to get the micropuncture dilator and sheath inserted. Angiography was then performed demonstrating vascular access in the proximal third of the common femoral artery just below the inguinal ligament. There is severe restenosis at the site just proximal to the anastomosis of the femoral to femoral bypass graft. Again with significant difficulty and over a Amplatz superstiff wire we were eventually able to insert a 5-French 11 cm sheath. A 5-French vertebral catheter was then used to selectively engage and inject the right innominate. This demonstrated severe ostial stenosis of at least 80% with somewhat eccentric and calcified. Utilizing a stiff angled glide we were eventually able to traverse this lesion as well as through the widely patent proximal right subclavian stent into the right brachial and over that wire advanced the vertebral catheter to the axillary artery. Selective angiography was then formed with the remainder of the right upper extremity. This demonstrated the following:
1. The right axillary artery is of modest caliber with mild diffuse disease throughout.
2. Just distal to the origin of the anterior and posterior circumflex humeral arteries is a complete occlusion of the brachial. There are also some collaterals originating from this point.
3. The right brachial then reconstitutes via collateral circulation the level approximately 5 or 6 cm above the antecubital fossa. There is no retrograde filling more proximally.
Disease at the access site the sheath was inserted and position for future removal under direct manual compression.
Result Impression
Severe stenosis of the ostial right innominate which is amenable to endovascular intervention however given the high-grade stenosis at the access site I was concerned with even advancing to a 7-French sheath which would be required for the intervention in that that sheath might prove occlusive and threatened the femoral to femoral graft. The right brachial occlusion does not appear amenable to endovascular intervention. Attempts at traversing the proximal cap of the occlusion would potentially threaten her major sources of collaterals supply and render the arm completely ischemic. Given the rest symptoms patient be admitted we'll obtain a surgical consultation. I've already discussed the case with Dr. X was performed one of her previous surgeries while her prior partner Dr. W had performed her previous vascular surgeries. It may be that a combination surgical intervention on the brachial lesion while also performing a retrograde axillary access intervention on the innominate would provide her best. approach for both lesions.
What do you think???? thanks!!
Procedure date: 7/9/14
Preprocedure diagnosis: Critical limb ischemia right upper extremity
Post procedure diagnosis: Critical limb ischemia right upper extremity; ostial right innominate high-grade stenosis; patent proximal right subclavian and stent; right brachial artery chronic total occlusion; high-grade restenosis of the proximal left common femoral artery just proximal to fem-fem bypass proximal graft anastomosis
Procedure: Right SideArm angiography of the left common femoral; right upper extremity selective angiography
Access: Left common femoral artery
EBL: 10 cc
Complications: None
Patient presents on outpatient basis secondary to resting right upper extremity discomfort. She was prepped and draped in usual sterile fashion. Access was obtained via the left common femoral artery utilizing a 5-French micropuncture kit. A significant degree of scar tissue was encountered in this process. Sequential dilation was required just to get the micropuncture dilator and sheath inserted. Angiography was then performed demonstrating vascular access in the proximal third of the common femoral artery just below the inguinal ligament. There is severe restenosis at the site just proximal to the anastomosis of the femoral to femoral bypass graft. Again with significant difficulty and over a Amplatz superstiff wire we were eventually able to insert a 5-French 11 cm sheath. A 5-French vertebral catheter was then used to selectively engage and inject the right innominate. This demonstrated severe ostial stenosis of at least 80% with somewhat eccentric and calcified. Utilizing a stiff angled glide we were eventually able to traverse this lesion as well as through the widely patent proximal right subclavian stent into the right brachial and over that wire advanced the vertebral catheter to the axillary artery. Selective angiography was then formed with the remainder of the right upper extremity. This demonstrated the following:
1. The right axillary artery is of modest caliber with mild diffuse disease throughout.
2. Just distal to the origin of the anterior and posterior circumflex humeral arteries is a complete occlusion of the brachial. There are also some collaterals originating from this point.
3. The right brachial then reconstitutes via collateral circulation the level approximately 5 or 6 cm above the antecubital fossa. There is no retrograde filling more proximally.
Disease at the access site the sheath was inserted and position for future removal under direct manual compression.
Result Impression
Severe stenosis of the ostial right innominate which is amenable to endovascular intervention however given the high-grade stenosis at the access site I was concerned with even advancing to a 7-French sheath which would be required for the intervention in that that sheath might prove occlusive and threatened the femoral to femoral graft. The right brachial occlusion does not appear amenable to endovascular intervention. Attempts at traversing the proximal cap of the occlusion would potentially threaten her major sources of collaterals supply and render the arm completely ischemic. Given the rest symptoms patient be admitted we'll obtain a surgical consultation. I've already discussed the case with Dr. X was performed one of her previous surgeries while her prior partner Dr. W had performed her previous vascular surgeries. It may be that a combination surgical intervention on the brachial lesion while also performing a retrograde axillary access intervention on the innominate would provide her best. approach for both lesions.