ttglasscock
Networker
Help with coding this. I just want to make sure I'm not missing something.
This is what I have:
37226 -RT Popliteal
37220 modifier 50 - EIAs (bilateral)
37222 x 2 - CIAs (bilateral)
37186 - Rt iliacs
37186 - Rt CFA
37228 - Rt ATA
75710 XU
PROCEDURE: Right leg arteriogram with intervention
PRE PROCEDURE DIAGNOSIS: right rest pain, pad
POST PROCEDURE DIAGNOSIS: right iliac occlusion, right leg thrombosis/thromboembolus
PROCEDURES PERFORMED:
1. US guided retrograde left CFA 6f sheath.
2. Catheter into aorta then right posterior tibial/anterior tibial.
3. Aortoiliac and right leg angiogram.
4. 100% occlusion in stent right common iliac artery responding to atherectomy/thrombectomy with Rex Revolution 1.66 then 6mm angioplasty
5. 100% occlusion in stent right external iliac artery responding to atherectomy/thrombectomy with Rex Revolution 1.66 then 6mm angioplasty.
6. 100% occlusion right common femoral artery responding to atherectomy/thrombectomy with Rex Revolution 1.66 then 6mm angioplasty.
7. 100% occlusion right p2 popliteal artery - treated with 6mm x 100mm Lifestent.
8. Mechanical thrombectomy and TPA infusion right popliteal, anterior tibial and posterior tibial arteries.
9. 3mm angioplasty right anterior and posterior tibial arteries.
10. 6mm angioplasty left common and external iliac artery tandem 75% stenoses.
ANESTHESIA/SEDATION:
Mild to moderate conscious sedation was administered with continuous vital signs and pulse oximetry monitoring by a registered nurse who was present in the procedure room and was not involved in the technical portion of the procedure. The sedation process was conducted under the supervision of the physician performing the procedure.
Sedation start at: 1334 hours
Sedation end at: 1600 hours
PREPARATION:
The site was prepared and draped and all elements of maximal sterile barrier technique including sterile gloves, sterile gown, mask, large sterile sheet, hand hygiene and cutaneous antisepsis with 2% chlorhexidine +70% isopropyl alcohol were used.
TECHNICAL/FINDINGS:
The benefits and potential risks of the procedure were explained to the patient and written informed consent was obtained. A full "Time-Out" procedure was performed using standard guidelines. The patient was placed supine on the fluoroscopy table and the left groin was prepped and draped in the usual sterile fashion. Following local anesthesia with 1% lidocaine the left common femoral artery was accessed under ultrasound guidance with a micropunture set. A permanent sonographic image was stored for documentation. This was exchanged over a guidewire for a 6 French sheath. Next, a 5 Omniflush catheter was advanced into the abdominal aorta for flush pelvic angiography.
Diagnostic:
Aorta patent.
Tandem LEFT common and external iliac artery 75% stenoses (6f sheath occlusive initially).
Right common/external iliac and CFA 100% occlusion, right iliac stents.
RLE:
Profunda patent, distal half of CFA patent.
SFA patent.
70% p1 popliteal stenosis.
Anterior tibial and peroneal patent, diminutive posterior tibial with delayed flow/distal at least 70% stenosis.
Intervention:
Flush catheter engaged into right CIA occlusion/stents.
Stiff glide into - then carefully through occlusion.
Flush catheter gently advanced into right SFA - angio confirms intraluminal/right leg runoff imaging.
Given history/tactile feedback this is likely subacute which typically comes with acute component (thrombus).
Our only reasonable device here was Rex Revolution 1.66.
Viper wire in.
Revolution performed right iliacs and CFA then 6mm angioplasty extended inflation.
Post intervention no residual stenosis - inline flow restored.
Runoff imaging reveals 100% occlusion of p1/adductor canal.
Sheath advanced over bifurcation carefully.
018 system.
Wire/catheter into posterior tibial artery.
Same device Rex revolution for thrombus performed popliteal, tibioperoneal and posterior tibial.
Again, no flow distal to adductor canal post-intervention.
Abrupt cessation of flow proximal popliteal - 6mm x 100 mm lifestent placed.
Popliteal patent after stent placement however filling defect at anterior tibial origin into TP trunk, nearly occlusive.
Multiple devices, angioplasty, TPA infusion, catheter aspiration thrombectomy performed - with some improvement in flow.
After some time - I realized we may be dealing with HIT - as it seems thrombus is forming rather than embolizing.
Regardless, wire/catheter into dorsalis pedis. Pull back angio reveals patent/inline single vessel.
IA nitro and TPA administered from popliteal.
Attention turned to left iliac.
Tandem stenosis in mid left common and mid left external were both treated with 6mm angioplasty. No residual stenosis.
6f angioseal.
COMPLICATIONS: None
ESTIMATED BLOOD LOSS: Minimal
IMPRESSION:
1. Total right common iliac through CFA occlusion - subacute with component of thrombus suspected - recanalized as above.
2. Right popliteal occlusion responding to stent placement.
3. Distal right leg emboli and suspected component of thrombus formation. Strongly encourage workup for HIT and NOAC short-course at minimum until workup complete/resolved.
This is what I have:
37226 -RT Popliteal
37220 modifier 50 - EIAs (bilateral)
37222 x 2 - CIAs (bilateral)
37186 - Rt iliacs
37186 - Rt CFA
37228 - Rt ATA
75710 XU
PROCEDURE: Right leg arteriogram with intervention
PRE PROCEDURE DIAGNOSIS: right rest pain, pad
POST PROCEDURE DIAGNOSIS: right iliac occlusion, right leg thrombosis/thromboembolus
PROCEDURES PERFORMED:
1. US guided retrograde left CFA 6f sheath.
2. Catheter into aorta then right posterior tibial/anterior tibial.
3. Aortoiliac and right leg angiogram.
4. 100% occlusion in stent right common iliac artery responding to atherectomy/thrombectomy with Rex Revolution 1.66 then 6mm angioplasty
5. 100% occlusion in stent right external iliac artery responding to atherectomy/thrombectomy with Rex Revolution 1.66 then 6mm angioplasty.
6. 100% occlusion right common femoral artery responding to atherectomy/thrombectomy with Rex Revolution 1.66 then 6mm angioplasty.
7. 100% occlusion right p2 popliteal artery - treated with 6mm x 100mm Lifestent.
8. Mechanical thrombectomy and TPA infusion right popliteal, anterior tibial and posterior tibial arteries.
9. 3mm angioplasty right anterior and posterior tibial arteries.
10. 6mm angioplasty left common and external iliac artery tandem 75% stenoses.
ANESTHESIA/SEDATION:
Mild to moderate conscious sedation was administered with continuous vital signs and pulse oximetry monitoring by a registered nurse who was present in the procedure room and was not involved in the technical portion of the procedure. The sedation process was conducted under the supervision of the physician performing the procedure.
Sedation start at: 1334 hours
Sedation end at: 1600 hours
PREPARATION:
The site was prepared and draped and all elements of maximal sterile barrier technique including sterile gloves, sterile gown, mask, large sterile sheet, hand hygiene and cutaneous antisepsis with 2% chlorhexidine +70% isopropyl alcohol were used.
TECHNICAL/FINDINGS:
The benefits and potential risks of the procedure were explained to the patient and written informed consent was obtained. A full "Time-Out" procedure was performed using standard guidelines. The patient was placed supine on the fluoroscopy table and the left groin was prepped and draped in the usual sterile fashion. Following local anesthesia with 1% lidocaine the left common femoral artery was accessed under ultrasound guidance with a micropunture set. A permanent sonographic image was stored for documentation. This was exchanged over a guidewire for a 6 French sheath. Next, a 5 Omniflush catheter was advanced into the abdominal aorta for flush pelvic angiography.
Diagnostic:
Aorta patent.
Tandem LEFT common and external iliac artery 75% stenoses (6f sheath occlusive initially).
Right common/external iliac and CFA 100% occlusion, right iliac stents.
RLE:
Profunda patent, distal half of CFA patent.
SFA patent.
70% p1 popliteal stenosis.
Anterior tibial and peroneal patent, diminutive posterior tibial with delayed flow/distal at least 70% stenosis.
Intervention:
Flush catheter engaged into right CIA occlusion/stents.
Stiff glide into - then carefully through occlusion.
Flush catheter gently advanced into right SFA - angio confirms intraluminal/right leg runoff imaging.
Given history/tactile feedback this is likely subacute which typically comes with acute component (thrombus).
Our only reasonable device here was Rex Revolution 1.66.
Viper wire in.
Revolution performed right iliacs and CFA then 6mm angioplasty extended inflation.
Post intervention no residual stenosis - inline flow restored.
Runoff imaging reveals 100% occlusion of p1/adductor canal.
Sheath advanced over bifurcation carefully.
018 system.
Wire/catheter into posterior tibial artery.
Same device Rex revolution for thrombus performed popliteal, tibioperoneal and posterior tibial.
Again, no flow distal to adductor canal post-intervention.
Abrupt cessation of flow proximal popliteal - 6mm x 100 mm lifestent placed.
Popliteal patent after stent placement however filling defect at anterior tibial origin into TP trunk, nearly occlusive.
Multiple devices, angioplasty, TPA infusion, catheter aspiration thrombectomy performed - with some improvement in flow.
After some time - I realized we may be dealing with HIT - as it seems thrombus is forming rather than embolizing.
Regardless, wire/catheter into dorsalis pedis. Pull back angio reveals patent/inline single vessel.
IA nitro and TPA administered from popliteal.
Attention turned to left iliac.
Tandem stenosis in mid left common and mid left external were both treated with 6mm angioplasty. No residual stenosis.
6f angioseal.
COMPLICATIONS: None
ESTIMATED BLOOD LOSS: Minimal
IMPRESSION:
1. Total right common iliac through CFA occlusion - subacute with component of thrombus suspected - recanalized as above.
2. Right popliteal occlusion responding to stent placement.
3. Distal right leg emboli and suspected component of thrombus formation. Strongly encourage workup for HIT and NOAC short-course at minimum until workup complete/resolved.