BonnieJ123
Networker
I am needing help with this one please. Not familiar with the crossover technique and after researching I don't think there is additional cpt code for it. Please see what you think. I have put cpt codes with notations to what I am considering. States distal tip in left external iliac artery but after watching video on crossover technique I think it is the tip of the wire and not the cath. Thank you
Procedure Performed: 36246 bundled but mod allowed, 75774, 75774,59 bundled but mod allowed
1. Right to left crossover with selective catheter placement in the left external iliac artery
2. Radiographic supervision interpretation of the left lower extremity angiogram- 75716,26 bundled but mod allowable
3. PTA and stent of the left popliteal artery with a 7 x 80 Eluvia stent 37226,lt
Anesthesia Type: Conscious Sedation
Estimated Blood Loss: Minimal
Complications:
None
Procedure Description:
The right common femoral artery was visualized with ultrasound. It was accessed with ultrasound guidance with a microneedle and a microsheath was placed. This was upsized to a standard 6 French sheath over an 035 wire. A 5 French special catheter was inserted over wire and used to intubate the left common iliac artery. Left lower extremity angio was performed the level of the popliteal artery. At this point decision was made to crossover. The advantage glide was taken down to the left common femoral artery and fortunately I was able to cross this highly diseased area and get the wire into the distal SFA. This allowed for me to cross over placing the distal tip in the left external iliac artery. A 6 x 65 destination was utilized for this. An 035 Nava cross catheter was placed over the wire and used to get across the popliteal stenosis. I exchanged for an 035 Supera core wire. Predilation of the left popliteal artery was performed with a 6 x 40 ultra verse balloon. A 7 x 80 Eluvia stent was placed across the popliteal stenosis and deployed. A 6 x 40 Athletics noncompliant balloon was used to post dilate this area at 20 atm. This took us from a 90% stenosis to 0% stenosis with excellent flow and no dissection or perforation. Was very difficult to get the balloon and stent catheters into position due to the severe left common femoral stenosis but fortunately I was able to get that accomplished without disrupting the left common femoral plaque. Completion angiography was performed of the left lower extremity as well as the foot.
Findings
Left lower extremity angiogram: Extremely tortuous iliac arteries.
Left common iliac artery: Patent
Left hypogastric: Patent
Left external iliac artery: Patent
Left common femoral artery: Heavily calcified, severely diseased, with an eccentric 90 to 95% stenosis involving a profundo with extremely poor flow.
Left profunda clearly has severe near occlusive ostial disease
Left SFA: Ostially/proximally there is severe disease which is a continuation of the common femoral disease. The remainder of the SFA is patent.
Left popliteal: Proximally is patent, mid vessel has a severe eccentric 80% stenosis. The distal popliteal is patent
Left anterior tibial artery: Occluded proximally
Left tibial peroneal trunk: Patent
Left peroneal: Patent supplying geniculate collateralization to the distal anterior tibial artery as well as dorsalis pedis as well as left posterior tibial artery
Left posterior tibial artery: Occluded mid vessel
Impression:
1. Critical Limb ischemia
2. Successful revascularization of popliteal artery.
Recommendations:
1. Vascular surgery referral for consideration of a left common femoral endarterectomy and patch repair.
2. I think he is a good candidate for endarterectomy, and if this is accomplished that will create inline flow to the foot by way of a single-vessel. The peroneal does supply geniculate collateralization to the posterior tibial as well as dorsalis pedis and this increased flow could very well heal that toe and eliminate his rest discomfort without needing to perform tibial intervention. However I would certainly defer to the vascular surgeon of record as a pertains to any future tibial interventions on this gentleman.
Procedure Performed: 36246 bundled but mod allowed, 75774, 75774,59 bundled but mod allowed
1. Right to left crossover with selective catheter placement in the left external iliac artery
2. Radiographic supervision interpretation of the left lower extremity angiogram- 75716,26 bundled but mod allowable
3. PTA and stent of the left popliteal artery with a 7 x 80 Eluvia stent 37226,lt
Anesthesia Type: Conscious Sedation
Estimated Blood Loss: Minimal
Complications:
None
Procedure Description:
The right common femoral artery was visualized with ultrasound. It was accessed with ultrasound guidance with a microneedle and a microsheath was placed. This was upsized to a standard 6 French sheath over an 035 wire. A 5 French special catheter was inserted over wire and used to intubate the left common iliac artery. Left lower extremity angio was performed the level of the popliteal artery. At this point decision was made to crossover. The advantage glide was taken down to the left common femoral artery and fortunately I was able to cross this highly diseased area and get the wire into the distal SFA. This allowed for me to cross over placing the distal tip in the left external iliac artery. A 6 x 65 destination was utilized for this. An 035 Nava cross catheter was placed over the wire and used to get across the popliteal stenosis. I exchanged for an 035 Supera core wire. Predilation of the left popliteal artery was performed with a 6 x 40 ultra verse balloon. A 7 x 80 Eluvia stent was placed across the popliteal stenosis and deployed. A 6 x 40 Athletics noncompliant balloon was used to post dilate this area at 20 atm. This took us from a 90% stenosis to 0% stenosis with excellent flow and no dissection or perforation. Was very difficult to get the balloon and stent catheters into position due to the severe left common femoral stenosis but fortunately I was able to get that accomplished without disrupting the left common femoral plaque. Completion angiography was performed of the left lower extremity as well as the foot.
Findings
Left lower extremity angiogram: Extremely tortuous iliac arteries.
Left common iliac artery: Patent
Left hypogastric: Patent
Left external iliac artery: Patent
Left common femoral artery: Heavily calcified, severely diseased, with an eccentric 90 to 95% stenosis involving a profundo with extremely poor flow.
Left profunda clearly has severe near occlusive ostial disease
Left SFA: Ostially/proximally there is severe disease which is a continuation of the common femoral disease. The remainder of the SFA is patent.
Left popliteal: Proximally is patent, mid vessel has a severe eccentric 80% stenosis. The distal popliteal is patent
Left anterior tibial artery: Occluded proximally
Left tibial peroneal trunk: Patent
Left peroneal: Patent supplying geniculate collateralization to the distal anterior tibial artery as well as dorsalis pedis as well as left posterior tibial artery
Left posterior tibial artery: Occluded mid vessel
Impression:
1. Critical Limb ischemia
2. Successful revascularization of popliteal artery.
Recommendations:
1. Vascular surgery referral for consideration of a left common femoral endarterectomy and patch repair.
2. I think he is a good candidate for endarterectomy, and if this is accomplished that will create inline flow to the foot by way of a single-vessel. The peroneal does supply geniculate collateralization to the posterior tibial as well as dorsalis pedis and this increased flow could very well heal that toe and eliminate his rest discomfort without needing to perform tibial intervention. However I would certainly defer to the vascular surgeon of record as a pertains to any future tibial interventions on this gentleman.