I need help on coding this procedure please. Can I code for the catheter placement in the SFA? I have codes 36246,37184,37185,37211, 75630-26. thank you in advance for your help
CLINICAL DATA: PREVIOUS VASCULAR SURGERY, BILATERAL LOWER EXTREMITY ISCHEMIA
ABDOMINAL AORTOGRAM WITH BILATERAL LOWER EXTREMITY RUN-OFFS, ANGIOJET THROMBECTOMY AND INITIATION OF THROMBOLYSIS
PROCEDURE: Informed consent was obtained from the patient. The patient had no palpable femoral pulses and therefore the left arm was chosen for access. The left arm was prepped and draped in the usual sterile fashion. 1% Lidocaine was used as local anesthetic. Using ultrasound guidance, the left brachial artery was accessed and a 5Fr sheath was placed in the left arm. Through this, a 5Fr pigtail catheter was advanced into the abdominal aorta and an abdominal aortogram was performed. Bilateral pelvic arteriograms were performed as well as bilateral lower extremity run-offs to the level of the knees.
Diagnostic arteriograms demonstrate complete occlusion of an indwelling infrarenal aortic endograft. The celiac and superior mesenteric arteries are patent as are the main renal arteries. Collaterals in the SMA reconstitute the IMA which in turn reconstitute both internal iliac arteries. Collaterals reconstitute the profunda femoris artery in the right upper thigh and the SFA in the left upper thigh.
The pigtail catheter was exchanged over a Rosen wire for a 5Fr vertebral catheter. In addition, a 6Fr shuttle sheath was placed to provide greater support. With the use of a glidewire the vertebral catheter was able to cannulate the right limb of the endograft and the catheter was advanced to the level of the right common femoral artery. Contrast was injected confirming thrombosis of the common femoral artery. The catheter was able to be manipulated into the right profunda. The catheter was removed over the Rosen wire. AngioJet thrombectomy of the right limb of the endograft as well as the native right external and common femoral arteries was performed. A contrast injection performed through the AngioJet catheter did demonstrate re-establishment of in-line flow through the endograft and into the right profunda. The AngioJet catheter was then re-exchanged for the vertebral catheter which was then used to select the left limb of the endograft and the catheter was advanced down to the level of the common femoral artery and subsequently into the proximal SFA. The catheter was removed over the Rosen wire and the AngioJet thrombectomy catheter was advanced through the guidewire and thrombectomy of the left limb of the endograft as well as the native left external and common femoral arteries was performed. Contrast was injected demonstrating some re-established flow on the left. Finally, an infusion catheter was left in place extending down the left limb of the endograft to the level of the left common femoral artery with sideholes above the endograft bifurcation in order to fill with TPA to go down the right limb. TPA infusion was started at 1 mg per hour. A peripheral Heparin drip was also started at 300 units per hour. The patient was transferred to the ICU in stable condition. There were no complications.
MEDICATIONS: Fentanyl 75 mcg, Versed 1.5 mg IV. Vital signs were monitored appropriately throughout the procedure by the nursing staff for a duration of 16 minutes.
CONTRAST: Visipaque 320 - 78 cc.
FLUORO TIME: 23.07 minutes.
IMPRESSION:
1. The initial arteriogram demonstrated complete occlusion of an indwelling aortobi-iliac endograft as well as native bilateral external iliac and common femoral arteries. In addition, there is occlusion of both superficial femoral arteries as well as the left profunda. It is not clear if these occlusions are chronic versus acute as the patient has no prior studies at this institution.
2. Successful debulking of the bifurcated endograft and native bilateral external iliac arteries using the AngioJet thrombectomy catheter. TPA infusion was initiated with the catheter positioned down the left limb of the endograft but the sideholes positioned above the endograft bifurcation in hopes that some of the TPA will go down the right side. A follow-up arteriogram will be performed the next day.
CLINICAL DATA: PREVIOUS VASCULAR SURGERY, BILATERAL LOWER EXTREMITY ISCHEMIA
ABDOMINAL AORTOGRAM WITH BILATERAL LOWER EXTREMITY RUN-OFFS, ANGIOJET THROMBECTOMY AND INITIATION OF THROMBOLYSIS
PROCEDURE: Informed consent was obtained from the patient. The patient had no palpable femoral pulses and therefore the left arm was chosen for access. The left arm was prepped and draped in the usual sterile fashion. 1% Lidocaine was used as local anesthetic. Using ultrasound guidance, the left brachial artery was accessed and a 5Fr sheath was placed in the left arm. Through this, a 5Fr pigtail catheter was advanced into the abdominal aorta and an abdominal aortogram was performed. Bilateral pelvic arteriograms were performed as well as bilateral lower extremity run-offs to the level of the knees.
Diagnostic arteriograms demonstrate complete occlusion of an indwelling infrarenal aortic endograft. The celiac and superior mesenteric arteries are patent as are the main renal arteries. Collaterals in the SMA reconstitute the IMA which in turn reconstitute both internal iliac arteries. Collaterals reconstitute the profunda femoris artery in the right upper thigh and the SFA in the left upper thigh.
The pigtail catheter was exchanged over a Rosen wire for a 5Fr vertebral catheter. In addition, a 6Fr shuttle sheath was placed to provide greater support. With the use of a glidewire the vertebral catheter was able to cannulate the right limb of the endograft and the catheter was advanced to the level of the right common femoral artery. Contrast was injected confirming thrombosis of the common femoral artery. The catheter was able to be manipulated into the right profunda. The catheter was removed over the Rosen wire. AngioJet thrombectomy of the right limb of the endograft as well as the native right external and common femoral arteries was performed. A contrast injection performed through the AngioJet catheter did demonstrate re-establishment of in-line flow through the endograft and into the right profunda. The AngioJet catheter was then re-exchanged for the vertebral catheter which was then used to select the left limb of the endograft and the catheter was advanced down to the level of the common femoral artery and subsequently into the proximal SFA. The catheter was removed over the Rosen wire and the AngioJet thrombectomy catheter was advanced through the guidewire and thrombectomy of the left limb of the endograft as well as the native left external and common femoral arteries was performed. Contrast was injected demonstrating some re-established flow on the left. Finally, an infusion catheter was left in place extending down the left limb of the endograft to the level of the left common femoral artery with sideholes above the endograft bifurcation in order to fill with TPA to go down the right limb. TPA infusion was started at 1 mg per hour. A peripheral Heparin drip was also started at 300 units per hour. The patient was transferred to the ICU in stable condition. There were no complications.
MEDICATIONS: Fentanyl 75 mcg, Versed 1.5 mg IV. Vital signs were monitored appropriately throughout the procedure by the nursing staff for a duration of 16 minutes.
CONTRAST: Visipaque 320 - 78 cc.
FLUORO TIME: 23.07 minutes.
IMPRESSION:
1. The initial arteriogram demonstrated complete occlusion of an indwelling aortobi-iliac endograft as well as native bilateral external iliac and common femoral arteries. In addition, there is occlusion of both superficial femoral arteries as well as the left profunda. It is not clear if these occlusions are chronic versus acute as the patient has no prior studies at this institution.
2. Successful debulking of the bifurcated endograft and native bilateral external iliac arteries using the AngioJet thrombectomy catheter. TPA infusion was initiated with the catheter positioned down the left limb of the endograft but the sideholes positioned above the endograft bifurcation in hopes that some of the TPA will go down the right side. A follow-up arteriogram will be performed the next day.