Operative Note - Copy of Note- Please Assist
Physician Lists: Abdominal Aortogram with Bilateral LE Run-Off and Selective Arteriogram - Left Tibioperoneal trunk. We have coded (36247-75625-75716 )The other procedures dictated in the note are already coded. Just need to verify our coding on this.
The patient brought to the catheterization lab. He was sterilely prepped and draped in the usual fashion. Safety check was performed to confirm correct patient and procedure. Following this, 1% Xylocaine was used to infiltrate the right groin and a percutaneous stick of the right common femoral artery was performed. A guidewire was passed, followed by a 5-French sheath. A pigtail catheter was placed into the upper abdomen and at this time an abdominal aortogram was performed. He had no significant aortoiliac disease. He had bilateral renal arteries with no significant stenosis. The pigtail catheter was then pulled back to the bifurcation. At this time, bilateral lower extremity runoff was performed. On the right side, he had wide open femoral, superficial femoral, popliteal and tibioperoneal trunk with 3-vessel runoff. On the left side, he had a wide open common femoral artery, superficial femoral artery and popliteal artery. However, he had evidence of embolization and thrombus involving the tibioperoneal trunk. The anterior tibial was occluded and the origins of both the peroneal and posterior tibial were occluded as well. At this time, having gone up and over with a Glidewire and a rim catheter, the groin 5-French sheath was exchanged for a 7-French Destination sheath. The patient was heparinized at this point in time. Using the Glidewire and Aqua catheter, I was able to get down selectively to the left popliteal region. At this time, selective arteriogram of the tibioperoneal trunk region was performed. Following this, the Aqua catheter was eventually advanced with the Glidewire into the posterior tibial artery. This was then exchanged for an 0.018 wire. Following this, using the AngioJet system, both a power pulse with 5 mg of tPA was infused into the thrombus in the tibioperoneal trunk. Twenty minutes were a alloted to allow this to function and then mechanical thrombectomy with the AngioJet catheter was performed. Following this, a selective arteriogram was performed of the left lower extremity via the Destination sheath. This showed that there was still some residual thrombus both at the peroneal origin and in the posterior tibial. Further passes with the AngioJet were performed, but again there was still some residual thrombus left upon completion. Therefore, I decided he would the thrombolysed overnight and so a UniFuse 10 cm long catheter was placed down into the tibioperoneal trunk and posterior tibial artery. One milligram of tPA was infused at that time and then he is going to be placed on a tPA drip at 1 mg per hour overnight. He did have some pain and discomfort with some dissolution or dissolving of the thrombus. The foot is still quite viable. Intermittent fentanyl and Versed was utilized throughout the procedure for IV conscious sedation. The plan is to bring him back tomorrow and reexamine the tibioperoneal trunk and runoff vessels at that time.