Can anyone help with the codes?
PREOPERATIVE DIAGNOSIS: Disabling claudication, bilateral lower extremities.
POSTOPERATIVE DIAGNOSIS: Disabling claudication, bilateral lower extremities.
PROCEDURES:
1. Ultrasound guidance for right common femoral artery cannulation.
2. Angiogram of the right iliac artery.
3. Selective catheterization of the proximal aorta.
4. Aortogram.
5. Left brachial artery cutdown.
6. Selective catheterization of thoracic aorta via the left brachial artery.
7. Angiogram of the thoracic aorta.
8. Selective catheterization of abdominal aorta.
9. Attempted angioplasty, attempted percutaneous transluminal angioplasty of
the left iliac artery.
10.Percutaneous transluminal angioplasty of the aorta and right iliac artery
using a 4 mm x 200 mm balloon, completion angiogram.
11.Percutaneous transluminal angioplasty of the distal aorta and right
common iliac artery using a 5 mm x 150 mm balloon, completion angiogram.
12.Placement of 7 mm x 59 mm iCAST stent, distal aorta and right proximal
common iliac artery.
13.Placement of a 6 mm x 38 mm iCAST stent, right mid to distal common
iliac artery.
14.Percutaneous transluminal angioplasty of the proximal stent as well as
the main body of the stent using a 7 mm x 40 mm balloon, completion
angiogram.
15.Placement of 7 mm x 27 mm Express LD stent, mid aorta.
16.Completion angiogram.
17.Repair (closure) of left brachial artery arteriotomy.
DESCRIPTION OF PROCEDURE:
Sterile sheath was placed on the GE Logiq
ultrasound probe, and using ultrasound guidance, the common femoral artery as
well as the superficial and deep femoral artery bifurcations was noted.
I was able to
cannulate the femoral artery with a 21-gauge Mini-Stick needle and pass a
guidewire. However, x-ray showed that the cannulated needle was below the
femoral head and the needle was in the common femoral artery, but it would be
best to cannulate the femoral artery directly over the femoral head for help
with compression afterwards and hemostasis. The guidewire was passed and it
was left in place. Then, using the guidewire as well as ultrasound guidance,
I was able to cannulate the right common femoral artery over the mid femoral
head. Guidewire was passed without difficulty and more inferior guidewire was
placed. A small 5-French mini sheath was placed and aortogram was performed,
which confirmed I was in the right iliac artery. The external iliac artery
appeared to be a fairly widely patent, but the mid iliac artery was occluded.
The 035 guidewire was then placed and the mini sheath was exchanged over for
standard 5-French sheath. Using an angled Glidewire as well as a glide
catheter, I was able to pass the guidewire up into the mid aorta and the glide
catheter passed over this fairly easily. There was good venous return, and
aortogram was performed which confirmed that I was in the true lumen of the
aorta. There was no extravasation, again showed that the distal aorta was
occluded. At this time, a cutdown was made on the left arm over the biceps
area and the brachial artery was then encircled with vessel loops. The
patient was given a bolus of heparin 5000 units IV. The brachial artery was
then cannulated with a mini stick needle and a guidewire was placed, and 5-
French sheath was then exchanged over for the mini sheath and using an angled
Glidewire as well as a glide catheter, I was able to pass the guidewire into
the distal aorta or into the thoracic aorta, but could not initially get the
guidewire to pass down into the descending thoracic aorta. Therefore,
angiogram of the thoracic aorta was performed, which showed takeoff of the
left subclavian artery from the thoracic aorta, and manipulating the Glidewire
and glide catheter, I was able to pass first the Glidewire down into the
descending thoracic aorta and followed by the Glidewire. I was able to pass
both the Glidewire as well as glide catheter down into the mid abdominal area.
A repeat aortogram was performed. This again showed smooth taper of the
thoracic aorta. The 035 Bentson guidewire was then placed, and the glide
catheter was removed. The 5-French sheath was removed and exchanged over 4-5
French Cook TriForce sheath. This was passed down into the distal abdominal
aorta. Using the angled Glidewire as well as the TriForce sheath, I could
pass the guidewire down into the origin of the left iliac artery, but despite
multiple manipulations, I could not get the guidewire to pass down into the
left common iliac artery. The guidewire began to go down the right iliac
artery, and it appeared that a false tract had been created. The Glidewire
had been passed down for attempted angioplasty of the left common iliac
artery, but again because I could not pass the guidewire down the left iliac
artery, this could not be performed.
At this time, attention was directed at performing angioplasty and stent of
the distal aorta, as well as the right iliac artery. Bentson guidewire was
passed up the right iliac artery to the distal aorta over the glide catheter.
Percutaneous transluminal angioplasty was then performed with a 4 mm x 200 mm
balloon up to 10 atmospheres for 3 minutes. Completion angiogram via the
TriForce from the left brachial artery showed improved flow down the right
iliac artery. Repeat angioplasty was then performed of the distal aorta and
right iliac artery using a 5 mm x 150 mm balloon up to 10 atmospheres for 3
minutes. Completion angiogram showed much improved results and no
extravasation. At this time, a 7 mm x 59 mm iCAST stent was then placed in
the distal aorta down to the right proximal common iliac artery. This was
deflated at 10 atmospheres for 1 minute. An oblique view was then performed
of the right iliac artery, therefore showing a good take off of the internal
iliac artery, and a second 6 mm x 38 mm iCAST stent was then deployed at 10
atmospheres for 3 minutes. Completion angiogram showed good results, but
there appeared to be a stenosis just proximal to the 7 mm stent. Therefore, a
repeat balloon angioplasty was then performed of this area using a 7 mm x 40
mm balloon up to 10 atmospheres for 2 minutes, and then angioplasty was then
performed of the overlapping area using 7 mm x 40 mm balloon up to 10
atmospheres for 2 minutes. The completion angiogram showed still what
appeared to be a recurrent stenosis. This was narrow and appeared to be a
fairly large branch going down into the pelvic branch. Because I wanted to
preserve this, I decided to use a bare metal stent. A 7 mm x 28 mm express LD
stent was then deployed at 10 atmospheres for 1 minute. Completion angiogram
showed excellent results proximally with no further stenosis of this area and
preservation of the side branch. There was good blood flow distally as well.
At this time, I was happy with the results. Initially, had contemplated doing
a fem-fem bypass at the same time, but with the sheath being on the left arm
for quite a long time, I was concerned about the patient being on the table
for another 2 hours, especially doing cutdowns on the groins, with her being
under anticoagulation, and it was decided it would be best in the patient's
interest to bring her back in 3-4 weeks for a fem-fem bypass. The left
brachial artery arteriotomy was then closed with 6-0 Prolene. There were
strong Doppler signals in the distal brachial artery after this was closed.
At this time, the patient's right groin sheath was removed and pressure was
held, probably for at least 25 minutes. The right groin sheath was being
held. The hemostasis was achieved of the left arm by placing a thrombinsoaked
Gelfoam around the wound. In addition, #19 round Blake drain was
brought out for inferior aspect incision, sewn in place with heavy nylon.
Subcutaneous tissue was then closed in 2 layers using a 3-0 Vicryl. Skin was
closed with staples. Dressings were applied. Examination the right groin
showed no evidence of hematoma in this area. Of note, there was much better
arterial outflow out of the sheath after the stents were
placed and we were happy with the results.
PREOPERATIVE DIAGNOSIS: Disabling claudication, bilateral lower extremities.
POSTOPERATIVE DIAGNOSIS: Disabling claudication, bilateral lower extremities.
PROCEDURES:
1. Ultrasound guidance for right common femoral artery cannulation.
2. Angiogram of the right iliac artery.
3. Selective catheterization of the proximal aorta.
4. Aortogram.
5. Left brachial artery cutdown.
6. Selective catheterization of thoracic aorta via the left brachial artery.
7. Angiogram of the thoracic aorta.
8. Selective catheterization of abdominal aorta.
9. Attempted angioplasty, attempted percutaneous transluminal angioplasty of
the left iliac artery.
10.Percutaneous transluminal angioplasty of the aorta and right iliac artery
using a 4 mm x 200 mm balloon, completion angiogram.
11.Percutaneous transluminal angioplasty of the distal aorta and right
common iliac artery using a 5 mm x 150 mm balloon, completion angiogram.
12.Placement of 7 mm x 59 mm iCAST stent, distal aorta and right proximal
common iliac artery.
13.Placement of a 6 mm x 38 mm iCAST stent, right mid to distal common
iliac artery.
14.Percutaneous transluminal angioplasty of the proximal stent as well as
the main body of the stent using a 7 mm x 40 mm balloon, completion
angiogram.
15.Placement of 7 mm x 27 mm Express LD stent, mid aorta.
16.Completion angiogram.
17.Repair (closure) of left brachial artery arteriotomy.
DESCRIPTION OF PROCEDURE:
Sterile sheath was placed on the GE Logiq
ultrasound probe, and using ultrasound guidance, the common femoral artery as
well as the superficial and deep femoral artery bifurcations was noted.
I was able to
cannulate the femoral artery with a 21-gauge Mini-Stick needle and pass a
guidewire. However, x-ray showed that the cannulated needle was below the
femoral head and the needle was in the common femoral artery, but it would be
best to cannulate the femoral artery directly over the femoral head for help
with compression afterwards and hemostasis. The guidewire was passed and it
was left in place. Then, using the guidewire as well as ultrasound guidance,
I was able to cannulate the right common femoral artery over the mid femoral
head. Guidewire was passed without difficulty and more inferior guidewire was
placed. A small 5-French mini sheath was placed and aortogram was performed,
which confirmed I was in the right iliac artery. The external iliac artery
appeared to be a fairly widely patent, but the mid iliac artery was occluded.
The 035 guidewire was then placed and the mini sheath was exchanged over for
standard 5-French sheath. Using an angled Glidewire as well as a glide
catheter, I was able to pass the guidewire up into the mid aorta and the glide
catheter passed over this fairly easily. There was good venous return, and
aortogram was performed which confirmed that I was in the true lumen of the
aorta. There was no extravasation, again showed that the distal aorta was
occluded. At this time, a cutdown was made on the left arm over the biceps
area and the brachial artery was then encircled with vessel loops. The
patient was given a bolus of heparin 5000 units IV. The brachial artery was
then cannulated with a mini stick needle and a guidewire was placed, and 5-
French sheath was then exchanged over for the mini sheath and using an angled
Glidewire as well as a glide catheter, I was able to pass the guidewire into
the distal aorta or into the thoracic aorta, but could not initially get the
guidewire to pass down into the descending thoracic aorta. Therefore,
angiogram of the thoracic aorta was performed, which showed takeoff of the
left subclavian artery from the thoracic aorta, and manipulating the Glidewire
and glide catheter, I was able to pass first the Glidewire down into the
descending thoracic aorta and followed by the Glidewire. I was able to pass
both the Glidewire as well as glide catheter down into the mid abdominal area.
A repeat aortogram was performed. This again showed smooth taper of the
thoracic aorta. The 035 Bentson guidewire was then placed, and the glide
catheter was removed. The 5-French sheath was removed and exchanged over 4-5
French Cook TriForce sheath. This was passed down into the distal abdominal
aorta. Using the angled Glidewire as well as the TriForce sheath, I could
pass the guidewire down into the origin of the left iliac artery, but despite
multiple manipulations, I could not get the guidewire to pass down into the
left common iliac artery. The guidewire began to go down the right iliac
artery, and it appeared that a false tract had been created. The Glidewire
had been passed down for attempted angioplasty of the left common iliac
artery, but again because I could not pass the guidewire down the left iliac
artery, this could not be performed.
At this time, attention was directed at performing angioplasty and stent of
the distal aorta, as well as the right iliac artery. Bentson guidewire was
passed up the right iliac artery to the distal aorta over the glide catheter.
Percutaneous transluminal angioplasty was then performed with a 4 mm x 200 mm
balloon up to 10 atmospheres for 3 minutes. Completion angiogram via the
TriForce from the left brachial artery showed improved flow down the right
iliac artery. Repeat angioplasty was then performed of the distal aorta and
right iliac artery using a 5 mm x 150 mm balloon up to 10 atmospheres for 3
minutes. Completion angiogram showed much improved results and no
extravasation. At this time, a 7 mm x 59 mm iCAST stent was then placed in
the distal aorta down to the right proximal common iliac artery. This was
deflated at 10 atmospheres for 1 minute. An oblique view was then performed
of the right iliac artery, therefore showing a good take off of the internal
iliac artery, and a second 6 mm x 38 mm iCAST stent was then deployed at 10
atmospheres for 3 minutes. Completion angiogram showed good results, but
there appeared to be a stenosis just proximal to the 7 mm stent. Therefore, a
repeat balloon angioplasty was then performed of this area using a 7 mm x 40
mm balloon up to 10 atmospheres for 2 minutes, and then angioplasty was then
performed of the overlapping area using 7 mm x 40 mm balloon up to 10
atmospheres for 2 minutes. The completion angiogram showed still what
appeared to be a recurrent stenosis. This was narrow and appeared to be a
fairly large branch going down into the pelvic branch. Because I wanted to
preserve this, I decided to use a bare metal stent. A 7 mm x 28 mm express LD
stent was then deployed at 10 atmospheres for 1 minute. Completion angiogram
showed excellent results proximally with no further stenosis of this area and
preservation of the side branch. There was good blood flow distally as well.
At this time, I was happy with the results. Initially, had contemplated doing
a fem-fem bypass at the same time, but with the sheath being on the left arm
for quite a long time, I was concerned about the patient being on the table
for another 2 hours, especially doing cutdowns on the groins, with her being
under anticoagulation, and it was decided it would be best in the patient's
interest to bring her back in 3-4 weeks for a fem-fem bypass. The left
brachial artery arteriotomy was then closed with 6-0 Prolene. There were
strong Doppler signals in the distal brachial artery after this was closed.
At this time, the patient's right groin sheath was removed and pressure was
held, probably for at least 25 minutes. The right groin sheath was being
held. The hemostasis was achieved of the left arm by placing a thrombinsoaked
Gelfoam around the wound. In addition, #19 round Blake drain was
brought out for inferior aspect incision, sewn in place with heavy nylon.
Subcutaneous tissue was then closed in 2 layers using a 3-0 Vicryl. Skin was
closed with staples. Dressings were applied. Examination the right groin
showed no evidence of hematoma in this area. Of note, there was much better
arterial outflow out of the sheath after the stents were
placed and we were happy with the results.