2210kelly@gmail.com
Networker
So far I have 36215, 75625-26, 75716-26, 36246? 75710-26?, this one is confusing me, really confusing to me is the "venous access established" what happened there?
The patient with history of lung CA for which he is undergoing chemotherapy at the
present. The patient otherwise has history of atrial fibrillation and poor R-wave progression noted per
EKG. The patient was seen in September 2014 with symptoms of bilateral lower extremity weakness.
The patient gave history of poor circulation as well as low back problems. The patient also specifically
referred to spinal stenosis as a diagnosis that he has been apprised of in the past. ABI of 0.96 was noted
on the right and 0.58 on the left. Pletal was added. The patient reported absence of any asymptomatic
response to the addition of Pie tal. The patient emphatically reported bilateral lower extremity pain focal
to the anterior thighs bilaterally. The patient states that symptoms are triggered by walking, but that he
is able to ambulate only minimally to begin with. The patient was not able to give clear history as to
whether or not sitting was necessary in order for symptoms to abate versus the cessation of activity by
itself to help in dissipation of the symptoms. CTA was suggestive of extensive and diffuse disease.
However, the angiographic findings pertaining to the left iliofemoral system was hard to reconcile with
ABI of 0.58. Hence, the patient is to proceed with invasive evaluation.
PROCEDURES:
1. Aortography.
2. Angiography of the left subclavian.
3. Bilateral lower extremity runoff.
TECHNIQUE:
The patient was premedicated with fentanyl and Versed. No palpable pulses were present in the left
common femoral. Faint pulse in the right common femoral. Calcification was also noted. Hence, the
decision to proceed with access from left brachial site. Ultrasound guidance was used to guide brachial
access. A 4-French sheath was placed. A 4-French pigtail catheter could not be directed advanced to
the ascending aorta. 1M diagnostic catheter and in conjunction with a Glidewire were utilized. Next, the
Storq wire was advanced to the right common iliac from above. Next, a pigtail catheter again could not
track beyond the thoracic aorta due to marked tortuosity I suspect. Next, the glide catheter was
advanced into the abdominal aorta. Manual injection from the left common iliac was performed. Next,
under fluoroscopic guidance with the Storq catheter tip positioned in the right common femoral. Venous
access was established. A 4-French sheath was placed. Next, pigtail catheter was advanced to the
abdominal aorta. Paradoxically and subsequent to bilateral lower extremity runoff was completed with
the benefit of DSA.
FINDINGS:
1. The abdominal aorta is affected by moderate diffuse narrowing and dense calcification. The left renal
artery is likely affected by a discrete stenosis proximally. The right renal artery is free of any luminal
irregularities bilaterally. Normal nephrotomogram was noted. No evidence of aneurysmal changes. No
evidence of stenotic process affecting the abdominal aorta.
2. Pelvic anatomy: Right common iliac is affected by a discrete lesion in its distal most extent at the
bifurcation. The stenosis is likely estimated at 50%. Otherwise, the right external iliac is affected by
mild luminal irregularities only. Right internal iliac is affected by mild stenosis at the level of the
ostium. The left common iliac is patent. The left external iliac is completely occluded at the level of the
ostium. The left internal iliac is subject to a discrete high-grade stenotic lesion. The left common
femoral is occluded. There is extensive collateral flow to the left common femoral region from the
hypogastric collaterals from the left.
3. Infrainguinal anatomy: The right common femoral is affected by dense calcification. The right SFA
is affected by mild diffuse disease. The proximal right popliteal is affected by a short 40% lesion. The
distal popliteal is substantially disease-free. The right anterior tibialis is seen to provide single vessel
flow to the level of the foot.
4. Left infrainguinal anatomy: Left common femoral is occluded as previously. Left SF A is occluded
in its proximal segment. The segment occluded on the left proximal SF A is likely 5-6cm in length. The
left SF A reconstitutes via profunda collaterals quite proximally. Distal left SF A just above the adductor
canal is affected by moderate disease. Left popliteal distal and proximal is substantially disease-free.
Left lower extremity is otherwise notable for presence of three-vessel flow to the level of the ankle and
left foot.
COMPLICATIONS:
None.
PACCESS SITE MANAGEMENT:
Manual compression was applied to the brachial and right common femoral access site.
SUMMARY:
1. Moderate diffuse narrowing of the abdominal aorta without any critical stenosis nor any aneurysmal
changes.
2. Suspected high-grade stenosis affecting the proximal portion of the left renal artery.
3. Chronic total occlusion of the left external iliac as well as the left common femoral.
4. Proximal portion of the left SFA is also occluded spanning likely a 5-6cm segment.
5. Severe disease affecting the right common femoral in conjunction with dense calcification.
6. Right lower extremity ABI of 0.96 and left lower extremity ABI of 0.58.
CLINICAL CORRELATION:
The discordance between the findings of the CTA, which did not identify any obstructive lesions
affecting the left iliofemoral system and the ABI of 0.58 on the left is clearly explained in terms of the
occlusion of the left external iliac as well as the left common femoral artery, which was identified
angiographically and which had not been noted per CT A study. The right lower extremity symptoms;
however, are consistent with the angiographic findings per CTA and per invasive studies. We will
continue with optimization of medical therapy as the symptoms reported by the patient would not be
consistent with the findings of the invasive evaluation today by way of vascular etiology. Spinal
stenosis and other potential orthopedic causes need to be explored further.
The patient with history of lung CA for which he is undergoing chemotherapy at the
present. The patient otherwise has history of atrial fibrillation and poor R-wave progression noted per
EKG. The patient was seen in September 2014 with symptoms of bilateral lower extremity weakness.
The patient gave history of poor circulation as well as low back problems. The patient also specifically
referred to spinal stenosis as a diagnosis that he has been apprised of in the past. ABI of 0.96 was noted
on the right and 0.58 on the left. Pletal was added. The patient reported absence of any asymptomatic
response to the addition of Pie tal. The patient emphatically reported bilateral lower extremity pain focal
to the anterior thighs bilaterally. The patient states that symptoms are triggered by walking, but that he
is able to ambulate only minimally to begin with. The patient was not able to give clear history as to
whether or not sitting was necessary in order for symptoms to abate versus the cessation of activity by
itself to help in dissipation of the symptoms. CTA was suggestive of extensive and diffuse disease.
However, the angiographic findings pertaining to the left iliofemoral system was hard to reconcile with
ABI of 0.58. Hence, the patient is to proceed with invasive evaluation.
PROCEDURES:
1. Aortography.
2. Angiography of the left subclavian.
3. Bilateral lower extremity runoff.
TECHNIQUE:
The patient was premedicated with fentanyl and Versed. No palpable pulses were present in the left
common femoral. Faint pulse in the right common femoral. Calcification was also noted. Hence, the
decision to proceed with access from left brachial site. Ultrasound guidance was used to guide brachial
access. A 4-French sheath was placed. A 4-French pigtail catheter could not be directed advanced to
the ascending aorta. 1M diagnostic catheter and in conjunction with a Glidewire were utilized. Next, the
Storq wire was advanced to the right common iliac from above. Next, a pigtail catheter again could not
track beyond the thoracic aorta due to marked tortuosity I suspect. Next, the glide catheter was
advanced into the abdominal aorta. Manual injection from the left common iliac was performed. Next,
under fluoroscopic guidance with the Storq catheter tip positioned in the right common femoral. Venous
access was established. A 4-French sheath was placed. Next, pigtail catheter was advanced to the
abdominal aorta. Paradoxically and subsequent to bilateral lower extremity runoff was completed with
the benefit of DSA.
FINDINGS:
1. The abdominal aorta is affected by moderate diffuse narrowing and dense calcification. The left renal
artery is likely affected by a discrete stenosis proximally. The right renal artery is free of any luminal
irregularities bilaterally. Normal nephrotomogram was noted. No evidence of aneurysmal changes. No
evidence of stenotic process affecting the abdominal aorta.
2. Pelvic anatomy: Right common iliac is affected by a discrete lesion in its distal most extent at the
bifurcation. The stenosis is likely estimated at 50%. Otherwise, the right external iliac is affected by
mild luminal irregularities only. Right internal iliac is affected by mild stenosis at the level of the
ostium. The left common iliac is patent. The left external iliac is completely occluded at the level of the
ostium. The left internal iliac is subject to a discrete high-grade stenotic lesion. The left common
femoral is occluded. There is extensive collateral flow to the left common femoral region from the
hypogastric collaterals from the left.
3. Infrainguinal anatomy: The right common femoral is affected by dense calcification. The right SFA
is affected by mild diffuse disease. The proximal right popliteal is affected by a short 40% lesion. The
distal popliteal is substantially disease-free. The right anterior tibialis is seen to provide single vessel
flow to the level of the foot.
4. Left infrainguinal anatomy: Left common femoral is occluded as previously. Left SF A is occluded
in its proximal segment. The segment occluded on the left proximal SF A is likely 5-6cm in length. The
left SF A reconstitutes via profunda collaterals quite proximally. Distal left SF A just above the adductor
canal is affected by moderate disease. Left popliteal distal and proximal is substantially disease-free.
Left lower extremity is otherwise notable for presence of three-vessel flow to the level of the ankle and
left foot.
COMPLICATIONS:
None.
PACCESS SITE MANAGEMENT:
Manual compression was applied to the brachial and right common femoral access site.
SUMMARY:
1. Moderate diffuse narrowing of the abdominal aorta without any critical stenosis nor any aneurysmal
changes.
2. Suspected high-grade stenosis affecting the proximal portion of the left renal artery.
3. Chronic total occlusion of the left external iliac as well as the left common femoral.
4. Proximal portion of the left SFA is also occluded spanning likely a 5-6cm segment.
5. Severe disease affecting the right common femoral in conjunction with dense calcification.
6. Right lower extremity ABI of 0.96 and left lower extremity ABI of 0.58.
CLINICAL CORRELATION:
The discordance between the findings of the CTA, which did not identify any obstructive lesions
affecting the left iliofemoral system and the ABI of 0.58 on the left is clearly explained in terms of the
occlusion of the left external iliac as well as the left common femoral artery, which was identified
angiographically and which had not been noted per CT A study. The right lower extremity symptoms;
however, are consistent with the angiographic findings per CTA and per invasive studies. We will
continue with optimization of medical therapy as the symptoms reported by the patient would not be
consistent with the findings of the invasive evaluation today by way of vascular etiology. Spinal
stenosis and other potential orthopedic causes need to be explored further.
