maine4me
Guru
Would someone help me with coding this note? Cardiovascular is not my area of expertise, so I need some guidance. The codes I got are 37227, 37235, 93451.
PERIPHERAL ARTERIAL CATHETERIZATION
Date of Procedure: February 25, 2014
Procedures performed:
1: Angioplasty alone of the left proximal superficial femoral artery (SFA) using a 5 x 40mm Chocolate balloon
2: Angioplasty with provisional stenting of the distal left SFA with placement of a 7 x 18 mm Everflex nitinol self expanding stent post dilated with a 6 mm diameter balloon
3: Orbital atherectomy with a CSI 1.25mm burr of the distal popliteal, tibial peroneal trunk, and proximal peroneal artery with angioplasty of 3 segments using a 3.0 x 18 mm Chocolate balloon
4: Right heart catheterization
Primary Care Physician: Dr. A
Referring Cardiologist: Myself
INDICATION: The patient is an 83-year-old woman with a complex past medical history who returns for a left leg intervention with critical limb ischemia, intermittent rest pain, and a nonhealing wound on her left foot. She underwent a diagnostic angiogram 2 weeks ago which showed multivessel occlusive disease. She has significant renal insufficiency and returns today for a staged intervention in an effort to minimize contrast nephropathy. Right heart catheterization will also be performed to optimally guide hydration with contrast exposure. Of note, creatinine post diagnostic procedure was 1.6 down from her baseline around 2.0.
PROCEDURE DETAILS: Informed consent was obtained. The patient was brought to the catheterization laboratory and prepped and draped in usual sterile fashion. A micropuncture kit was used to obtain arterial access in the right common femoral artery. A 6 French venous sheath was placed in the right common femoral vein using an over-the-wire technique. Angiography confirmed position in the common femoral artery above the bifurcation. A 5 French RIM catheter was used to advance a Terumo Advantage wire over the aortic bifurcation and into the left SFA. A 65cm Destination sheath was then advanced into the mid SFA. Significant pressure dampening across the proximal lesion was noted with a 65 mmHg peak to peak gradient recorded on pullback. We proceeded directly to intervention which is outlined below. After successful complex intervention, the LAD long 6 French sheath was exchanged for a short 6 French sheath which was sutured in place. A right heart catheterization was then performed with pressure measurement in the right atrium, right ventricle, pulmonary artery, and pulmonary capillary wedge positions.
HEMODYNAMIC FINDINGS (mmHg):
RA(a,v,m): 21, 18, 13
RV(s/d,EDP): 48/9, 18
PA(s/d/m): 48/21, 27
PCWP(a,v,m): 23, 24, 17
Ao(s/d,m): 130/60, 82
Oxygen Saturations (mg/dl):
PA: 67% on room air
LV: 98% on room air
ANGIOGRAPHIC FINDINGS:
1: Please refer to the full diagnostic report from the angiogram performed 2/11/2014.
PERCUTANEOUS INTERVENTION:
1: The patient was given unfractionated heparin. A Confienza 0.014" wire was advanced across the proximal SFA lesion with the wire tip at the distal occlusion. A 5 x 40 mm Chocolate balloon was used to dilate the proximal SFA lesion at 6 atmospheres. Followup angiography revealed an excellent balloon only result. I then focused on the distal SFA occlusion. A Viance crossing catheter was used in combination with the Confienza wire to carefully and successfully cross the distal SFA occlusion. A 3.0 x 18 mm balloon was used to open up the occluded segment and restore antegrade flow. Next, the distal SFA segment was redilated with the 5 x 40 mm Chocolate balloon. I then turned my attention to the distal popliteal, tibial peroneal trunk, and peroneal artery disease. The Confianza wire was exchanged for a Viper wire with the tip positioned in the distal peroneal. CSI orbital atherectomy was then performed and the distal popliteal, tibial peroneal trunk, and proximal peroneal artery. Followup angiography revealed a reasonable postatherectomy result. Next a 3.0 x 80 mm Chocolate balloon was used to dilate the distal popliteal, tibial peroneal trunk, and proximal peroneal artery. Followup angiography revealed excellent angiographic result. Next, a 7 x 80 mm Everflex self-expanding stent was deployed in the distal SFA across the previously occluded segment. The stent was post dilated at 10 atmospheres with a 6 mm balloon taking care to stay within the stented margins. Followup angiography of the stented segment revealed an excellent result. I then elected to repeat angioplasty of the proximal SFA stenosis with the 5 mm diameter Chocolate balloon at 10 atmospheres. Followup selective angiography of the proximal SFA showed an excellent balloon only result. Chase bolus digital subtraction with runoff to the foot was then performed which showed an outstanding angiographic result with 2 vessel continuous runoff to the foot and no evidence of distal embolization.
FINAL RESULT: 20% residual proximal SFA stenosis, 0% residual distal SFA in-stent stenosis, and less than 20% residual stenosis in the distal popliteal, tibial peroneal trunk and proximal peroneal artery treated with atherectomy and angioplasty alone
Closure device: None. The sheaths were sutured in place.
Complications: None
ASSESSMENT:
1: Successful complex intervention of the left leg with angioplasty of the proximal SFA, angioplasty and stent placement of the distal SFA, and atherectomy followed by angioplasty alone of the distal popliteal, tibial peroneal trunk, and proximal peroneal arteries
2: Moderately elevated filling pressures.
CONCLUSIONS and RECOMMENDATIONS:
1: Routine post peripheral intervention monitoring and medical therapy. I will hydrate the patient with 150 cc an hour for the next 10 hours and plan to watch creatinine closely.
2: Continue excellent wound care with Dr.P - I am very optimistic the left foot wound will heal rapidly.
3: We will need to watch with duplex surveillance as she is at fairly significant risk for restenosis. I will continue to follow her closely in the office.
PERIPHERAL ARTERIAL CATHETERIZATION
Date of Procedure: February 25, 2014
Procedures performed:
1: Angioplasty alone of the left proximal superficial femoral artery (SFA) using a 5 x 40mm Chocolate balloon
2: Angioplasty with provisional stenting of the distal left SFA with placement of a 7 x 18 mm Everflex nitinol self expanding stent post dilated with a 6 mm diameter balloon
3: Orbital atherectomy with a CSI 1.25mm burr of the distal popliteal, tibial peroneal trunk, and proximal peroneal artery with angioplasty of 3 segments using a 3.0 x 18 mm Chocolate balloon
4: Right heart catheterization
Primary Care Physician: Dr. A
Referring Cardiologist: Myself
INDICATION: The patient is an 83-year-old woman with a complex past medical history who returns for a left leg intervention with critical limb ischemia, intermittent rest pain, and a nonhealing wound on her left foot. She underwent a diagnostic angiogram 2 weeks ago which showed multivessel occlusive disease. She has significant renal insufficiency and returns today for a staged intervention in an effort to minimize contrast nephropathy. Right heart catheterization will also be performed to optimally guide hydration with contrast exposure. Of note, creatinine post diagnostic procedure was 1.6 down from her baseline around 2.0.
PROCEDURE DETAILS: Informed consent was obtained. The patient was brought to the catheterization laboratory and prepped and draped in usual sterile fashion. A micropuncture kit was used to obtain arterial access in the right common femoral artery. A 6 French venous sheath was placed in the right common femoral vein using an over-the-wire technique. Angiography confirmed position in the common femoral artery above the bifurcation. A 5 French RIM catheter was used to advance a Terumo Advantage wire over the aortic bifurcation and into the left SFA. A 65cm Destination sheath was then advanced into the mid SFA. Significant pressure dampening across the proximal lesion was noted with a 65 mmHg peak to peak gradient recorded on pullback. We proceeded directly to intervention which is outlined below. After successful complex intervention, the LAD long 6 French sheath was exchanged for a short 6 French sheath which was sutured in place. A right heart catheterization was then performed with pressure measurement in the right atrium, right ventricle, pulmonary artery, and pulmonary capillary wedge positions.
HEMODYNAMIC FINDINGS (mmHg):
RA(a,v,m): 21, 18, 13
RV(s/d,EDP): 48/9, 18
PA(s/d/m): 48/21, 27
PCWP(a,v,m): 23, 24, 17
Ao(s/d,m): 130/60, 82
Oxygen Saturations (mg/dl):
PA: 67% on room air
LV: 98% on room air
ANGIOGRAPHIC FINDINGS:
1: Please refer to the full diagnostic report from the angiogram performed 2/11/2014.
PERCUTANEOUS INTERVENTION:
1: The patient was given unfractionated heparin. A Confienza 0.014" wire was advanced across the proximal SFA lesion with the wire tip at the distal occlusion. A 5 x 40 mm Chocolate balloon was used to dilate the proximal SFA lesion at 6 atmospheres. Followup angiography revealed an excellent balloon only result. I then focused on the distal SFA occlusion. A Viance crossing catheter was used in combination with the Confienza wire to carefully and successfully cross the distal SFA occlusion. A 3.0 x 18 mm balloon was used to open up the occluded segment and restore antegrade flow. Next, the distal SFA segment was redilated with the 5 x 40 mm Chocolate balloon. I then turned my attention to the distal popliteal, tibial peroneal trunk, and peroneal artery disease. The Confianza wire was exchanged for a Viper wire with the tip positioned in the distal peroneal. CSI orbital atherectomy was then performed and the distal popliteal, tibial peroneal trunk, and proximal peroneal artery. Followup angiography revealed a reasonable postatherectomy result. Next a 3.0 x 80 mm Chocolate balloon was used to dilate the distal popliteal, tibial peroneal trunk, and proximal peroneal artery. Followup angiography revealed excellent angiographic result. Next, a 7 x 80 mm Everflex self-expanding stent was deployed in the distal SFA across the previously occluded segment. The stent was post dilated at 10 atmospheres with a 6 mm balloon taking care to stay within the stented margins. Followup angiography of the stented segment revealed an excellent result. I then elected to repeat angioplasty of the proximal SFA stenosis with the 5 mm diameter Chocolate balloon at 10 atmospheres. Followup selective angiography of the proximal SFA showed an excellent balloon only result. Chase bolus digital subtraction with runoff to the foot was then performed which showed an outstanding angiographic result with 2 vessel continuous runoff to the foot and no evidence of distal embolization.
FINAL RESULT: 20% residual proximal SFA stenosis, 0% residual distal SFA in-stent stenosis, and less than 20% residual stenosis in the distal popliteal, tibial peroneal trunk and proximal peroneal artery treated with atherectomy and angioplasty alone
Closure device: None. The sheaths were sutured in place.
Complications: None
ASSESSMENT:
1: Successful complex intervention of the left leg with angioplasty of the proximal SFA, angioplasty and stent placement of the distal SFA, and atherectomy followed by angioplasty alone of the distal popliteal, tibial peroneal trunk, and proximal peroneal arteries
2: Moderately elevated filling pressures.
CONCLUSIONS and RECOMMENDATIONS:
1: Routine post peripheral intervention monitoring and medical therapy. I will hydrate the patient with 150 cc an hour for the next 10 hours and plan to watch creatinine closely.
2: Continue excellent wound care with Dr.P - I am very optimistic the left foot wound will heal rapidly.
3: We will need to watch with duplex surveillance as she is at fairly significant risk for restenosis. I will continue to follow her closely in the office.