suela923@aol.com
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Would you bill 37221, 37223 for the iliac stents? I thought that the distal left common into proximal left external iliac artery would be considered one code as per the CPT book pg. 223 regarding lesions of one vessel territory extends to another but are opened with one therapy. Your thoughts???? Thanks!!
Access: Bilateral common femoral artery access.
Patient presents in a fasting state for diagnostic angiography and possible intervention on the basis of lifestyle limiting bilateral lower extremity claudication symptoms and suggestion of pelvic inflow as well as possible bilateral superficial femoral disease by arterial duplex. Access was initially obtained via the right common femoral artery utilizing a micropuncture kit. This demonstrated a high bifurcation with initial access point in the bifurcation proper. The micro-sheath was removed, and direct manual compression applied for 5 minutes. Repeat access was then obtained in the proximal common femoral at the level of the 1st 1/3 of the femoral head. Repeat micro-sheath injection demonstrated placement above the high bifurcation. A 5-French 11 cm sheath was therefore inserted over a 0.035 wire. A 5-French pigtail catheter was placed in the infrarenal abdominal aorta for nonselective aortography and bilateral iliac angiography. This demonstrated high-grade stenosis of the bilateral common iliac arteries, both approximately 75-80% in severity with moderate calcification. There was also an eccentric calcified 75% stenosis within the left distal common iliac into the proximal left external iliac artery bridging the hypogastric origin. On the basis of the above findings, the patient was considered amenable to percutaneous endovascular intervention of the iliac lesions. Access was then obtained via the left common femoral artery utilizing the same micropuncture kit with subsequent insertion of a 7-French 11 cm sheath. We also substituted out the 5-French right-sided sheath for a 7 French 11 cm sheath over a 0.035 wire. Long stork wires were advanced through each sheath and placed into the abdominal aorta. Initial predilatation of all 3 identified iliac lesions was performed with a 6 mm x 40 mm Powerflex balloon followed by sequential dilatation of the left common iliac, left external iliac, and right common iliac lesion with an 8 mm x 20 mm Powerflex balloon. This resulted in no apparent dissection with adequate patency for stent delivery. A 9 x 39 Genesis balloon expandable stent was advanced to the ostium of the right common iliac artery while a 9 x 29 mm Genesis balloon expandable stent was advanced to the ostium of the left common iliac artery. Bilateral sheath SideArm injections confirmed ostial placement. These were then deployed in a simultaneous inflation technique. Subsequently, a 10 mm x 40 mm Smart self-expanding nitinol stent was placed across the distal left common into proximal left external iliac artery, and this was then post dilated with the 8 mm x 20 mm Powerflex balloon. A 5F Pigtail catheter was once again placed in the infrarenal abdominal aorta, and repeat angiography demonstrated flush ostial placement of both balloon-expandable common iliac stents with 0% residual stenosis at those sites. There was approximately 10% residual stenosis in the self-expanding stent placed from the distal common to the proximal left external iliac artery. There was no hemodynamic gradient across this lesion by pressure sampling pullback. Both wires were then removed, and sequential sheath SideArm angiography was performed 1st via the right sheath down the entirety of the right lower extremity, and 2nd via the left sheath and the entirety of that extremity. The findings are as follows:
There is eccentric diffuse calcified 50% disease in the mid right SFA. There is then a discrete right SFA possible complete occlusion versus 99% stenosis with small patent micro-channel at the start of the adductor canal. Focal calcified 70% right proximal popliteal lesion. There is moderate diffuse disease in the ostial through proximal right anterior tibial artery with otherwise patent 3-vessel runoff to the foot predominantly via the right posterior tibial.
There is a discrete chronic total occlusion of the distal left common femoral artery immediately prior to the bifurcation with robust bridging collaterals. There is moderate diffuse 50% disease in the ostial through proximal left SFA with eccentric calcification. There are tandem discrete distal 60-70% focal calcified stenosis in the left SFA immediately prior to and in the middle of the adductor canal. The left popliteal is relatively free of disease. There is only mild diffuse disease in the left tibial vessels with 3-vessel runoff to the foot predominantly via the larger left posterior tibial artery
Access: Bilateral common femoral artery access.
Patient presents in a fasting state for diagnostic angiography and possible intervention on the basis of lifestyle limiting bilateral lower extremity claudication symptoms and suggestion of pelvic inflow as well as possible bilateral superficial femoral disease by arterial duplex. Access was initially obtained via the right common femoral artery utilizing a micropuncture kit. This demonstrated a high bifurcation with initial access point in the bifurcation proper. The micro-sheath was removed, and direct manual compression applied for 5 minutes. Repeat access was then obtained in the proximal common femoral at the level of the 1st 1/3 of the femoral head. Repeat micro-sheath injection demonstrated placement above the high bifurcation. A 5-French 11 cm sheath was therefore inserted over a 0.035 wire. A 5-French pigtail catheter was placed in the infrarenal abdominal aorta for nonselective aortography and bilateral iliac angiography. This demonstrated high-grade stenosis of the bilateral common iliac arteries, both approximately 75-80% in severity with moderate calcification. There was also an eccentric calcified 75% stenosis within the left distal common iliac into the proximal left external iliac artery bridging the hypogastric origin. On the basis of the above findings, the patient was considered amenable to percutaneous endovascular intervention of the iliac lesions. Access was then obtained via the left common femoral artery utilizing the same micropuncture kit with subsequent insertion of a 7-French 11 cm sheath. We also substituted out the 5-French right-sided sheath for a 7 French 11 cm sheath over a 0.035 wire. Long stork wires were advanced through each sheath and placed into the abdominal aorta. Initial predilatation of all 3 identified iliac lesions was performed with a 6 mm x 40 mm Powerflex balloon followed by sequential dilatation of the left common iliac, left external iliac, and right common iliac lesion with an 8 mm x 20 mm Powerflex balloon. This resulted in no apparent dissection with adequate patency for stent delivery. A 9 x 39 Genesis balloon expandable stent was advanced to the ostium of the right common iliac artery while a 9 x 29 mm Genesis balloon expandable stent was advanced to the ostium of the left common iliac artery. Bilateral sheath SideArm injections confirmed ostial placement. These were then deployed in a simultaneous inflation technique. Subsequently, a 10 mm x 40 mm Smart self-expanding nitinol stent was placed across the distal left common into proximal left external iliac artery, and this was then post dilated with the 8 mm x 20 mm Powerflex balloon. A 5F Pigtail catheter was once again placed in the infrarenal abdominal aorta, and repeat angiography demonstrated flush ostial placement of both balloon-expandable common iliac stents with 0% residual stenosis at those sites. There was approximately 10% residual stenosis in the self-expanding stent placed from the distal common to the proximal left external iliac artery. There was no hemodynamic gradient across this lesion by pressure sampling pullback. Both wires were then removed, and sequential sheath SideArm angiography was performed 1st via the right sheath down the entirety of the right lower extremity, and 2nd via the left sheath and the entirety of that extremity. The findings are as follows:
There is eccentric diffuse calcified 50% disease in the mid right SFA. There is then a discrete right SFA possible complete occlusion versus 99% stenosis with small patent micro-channel at the start of the adductor canal. Focal calcified 70% right proximal popliteal lesion. There is moderate diffuse disease in the ostial through proximal right anterior tibial artery with otherwise patent 3-vessel runoff to the foot predominantly via the right posterior tibial.
There is a discrete chronic total occlusion of the distal left common femoral artery immediately prior to the bifurcation with robust bridging collaterals. There is moderate diffuse 50% disease in the ostial through proximal left SFA with eccentric calcification. There are tandem discrete distal 60-70% focal calcified stenosis in the left SFA immediately prior to and in the middle of the adductor canal. The left popliteal is relatively free of disease. There is only mild diffuse disease in the left tibial vessels with 3-vessel runoff to the foot predominantly via the larger left posterior tibial artery