Rita Bartholomew
Guru
As the iliac territory is coded differently, would the gluteal arteries be coded with 0238T's and 37222's? Also, should I add 75774 here for the additional images of right leg and calf?
PROCEDURES PERFORMED:
1. Angiogram of the aorta and bilateral lower extremities.
2. Rotational arthrectomy and angioplasty of the right superficial femoral artery (CSI 2.0, 6 mm balloon).
3. Rotational arthrectomy and balloon angioplasty of the left anterior gluteal artery (CSI 1.25 device, 3 mm balloon).
4. Rotational atherectomy and angioplasty of the left posterior gluteal artery (CSI 1.25 mm, 3 mm balloon).
5. Rotational arthrectomy and balloon angioplasty of the left hypogastric artery (CSI 1.25 mm, 5 mm balloon).
SURGEON: Xxxx Xxxxx, MD
ANESTHESIA: Local with moderate sedation.
EBL: Minimal.
COMPLICATIONS: None.
RADIOLOGIC FINDINGS:
1. The abdominal aorta was patent with solitary renal arteries bilaterally. On the right side there appeared to be a greater than 70% right renal artery stenosis. On the left side, the renal artery appeared to bifurcate immediately, or there were possibly 2 left renal arteries with origins very near each other.
The abdominal aorta in the infrarenal position was moderately to severely diseased with atherosclerosis and an ulcerated area was noted on the left anterolateral side wall of the abdominal aorta. That or this was a small pseudoaneurysm off the anterolateral side wall of the abdominal aorta.
Both common iliac arteries were patent with no hemodynamically significant stenosis noted. Both external iliac arteries were also patent with no hemodynamically significant stenosis noted. The right hypogastric artery was patent. The left hypogastric artery had a 50% stenosis at its origin. This branched into the anterior and posterior gluteal arteries, both of which had very significant appearing strictures of greater than 80%.
On the right side, the common femoral artery was patent. The superficial femoral and profunda femoris arteries were patent. The profundus femoris artery had an area of 50 to 60% stenosis approximately 8 cm from its origin. The SFA had a stenosis approximately 10 cm from its origin, which was approximately 70 to 80% stenotic.
The SFA had diffuse disease and gave rise to a popliteal artery which had 50 to 60% stenosis in the above to mid popliteal artery. The popliteal artery below the knee was patent. This then gave rise to very small appearing tibial arteries. The posterior tibial artery was the dominant artery on the right. The anterior tibial artery was also patent and the peroneal artery was also patent.
On the left side, the common femoral artery had approximately 40% stenosis. The profunda femoris artery was patent and the superficial femoral artery was patent. The popliteal artery was patent. This gave rise to posterior tibial and peroneal arteries, of which the posterior tibial artery was the dominant artery. The anterior tibial artery was not well visualized.
I was able to selectively catheterize the right superficial femoral artery and the lesion was treated with first rotational arthrectomy using a CSI 2 mm device at low, medium, and high speeds and this was followed by a balloon angioplasty. A 6 mm x 60 mm Sterling balloon was used and completion arteriogram showed significant improvement of the lesion with approximately 25% residual stenosis. Thus the run off was significantly improved.
After selectively catheterizing the left hypogastric artery from the left side, I determined that the right-sided approach would be better, and so a right-sided access was obtained. The left hypogastric artery, left anterior gluteal artery, and left posterior gluteal artery were selectively catheterized, treated with rotational arthrectomy and given balloon angioplasty. The posterior gluteal artery did not have a very good result. The anterior tibial artery had a residual of less than 30% stenosis and flow was significantly improved in the hypogastric artery following arthrectomy angioplasty. A 5 mm balloon was used in the hypogastric artery as noted above and 3 mm balloons were used in the gluteal arteries.
There were no complications. Upon completion, Angio-Seals were used bilaterally. Number 6 French access was used bilaterally.
PROCEDURE REPORT: The patient was taken to the cardiac catheterization laboratory where she was placed on the table in a dorsal recumbent position. After excellent induction with moderate sedation, the skin of the groin areas were prepped and draped in a standard sterile fashion. I then called a time-out for the correct patient and procedural identification per Xxxxxxx Hospital protocol. Under local anesthesia, I accessed the left common femoral artery in the retrograde direction using ultrasound guidance and a micropuncture needle. The needle accessed easily into the artery and the 0.01 inch guide wire advanced easily into the artery. Over the guide wire, a 5 French sheath was inserted. Through the 5 French sheath, an Omni Flush catheter was inserted and positioned to the L1-L2 vertebral body level, at which point the guide wire was removed, both were removed from the catheter and an AP angiogram of the abdominal aorta was obtained. I also administered 3000 units of unfractionated heparin IV at this time.
I then pulled the catheter down to the aortic bifurcation where oblique images of the iliofemoral and pelvic runoff were obtained. Next, maintaining the catheter in the distal abdominal aorta, a bolus chase angiogram of both lower extremities was performed.
I then selectively catheterized the right superficial femoral artery from the left side and additional images of the right leg and calf were obtained to further elucidate the runoff on the right.
I placed a stiff wire in the right superficial femoral artery and then over the stiff wire, a 6 French Balkan sheath were inserted up and over the aortic bifurcation. The guide wire was exchanged over a catheter for a viper wire and a total of 70 mg per kg of heparin IV was administered. Next, a CSI device measuring 2 mm in diameter was used to treat the right superficial femoral artery lesion at low, medium, and high speeds. A 6 mm x 4 cm angioplasty balloon was then used to post dilate the lesion at 3 atmospheres for 2 minutes. The completion arteriogram showed significant improvement in the lesion. I accepted this result. Next, I selectively catheterized the left hypogastric artery from the right and obtained several additional images of the left hypogastric artery on different planes to better elucidate the lesions there. I decided that the angle into the hypogastric artery was quite steep from the left side and that a right-sided puncture was going to be required to treat these arteries. Thus, again using local anesthesia and ultrasound guidance, I accessed the right common femoral artery. The 6 French sheath was removed from the left side and an Angio-Seal device was deployed. The 5 French sheath in the right groin was then exchanged for the 6 French Balkan sheath. I selectively catheterized the right common femoral artery from the left with a guide wire and then inserted the Balkan up and over the aortic bifurcation. Next I used a comfy catheter in conjunction with a glidewire to selectively catheterize the left hypogastric artery. Using a PT Graphix wire, I was able to cross into the posterior gluteal artery. I was able to advance the sheath over the Comfy catheter and wire and into the left hypogastric artery. Next the Comfy catheter was removed and a CSI 1.25 mm device was used to treat the left posterior gluteal artery at low speed for 30 seconds. This was repeated 3 additional times with interval breaks to allow for clearance of the microscopic debris created by the device.
I then selected a 3 mm angioplasty balloon and used this to post dilate the artery. The artery was noted to be quite resistant to angioplasty and a significant "waist" was noted in the 3 mm balloon which popped at 10 atmospheres. Balloon angioplasty persisted for 2 minutes and the 3 mm balloon was deflated and a completion angiogram was performed. There still appeared to be residual of 25 to 30% or more stenosis in the artery, so a 2nd angioplasty was performed with a similar result.
I then selectively catheterized the anterior tibial artery and exchanged a crossing wire for the viper wire. The anterior tibial artery stenosis was then treated at low speed x4 followed by medium speed x1; 25 to 30 second treatments were performed followed by 25 to 30 second intervals of rest to allow for clearance of the debris. The 3 mm x 2 cm balloon was again used to treat the anterior gluteal artery lesion. A 2-minute inflation was performed and full effacement of the balloon was noted. Completion imaging showed improvement of the anterior and posterior gluteal arteries. The left hypogastric artery was also treated in its origin with the 1.25 mm device at medium and high speeds. A 5 cm x 4 cm angioplasty balloon was used to perform balloon angioplasty here and full effacement of the balloon was noted. The balloon angioplasty persisted for 2 minutes and upon deflation completion angiogram showed improvement of flow into the left hypogastric region.
I accepted this result. An Angio-Seal device was then deployed in the right femoral position. There were no complications and Ms. Xxxx tolerated the procedure well. The sponge and needle counts following the case were correct x2.
PROCEDURES PERFORMED:
1. Angiogram of the aorta and bilateral lower extremities.
2. Rotational arthrectomy and angioplasty of the right superficial femoral artery (CSI 2.0, 6 mm balloon).
3. Rotational arthrectomy and balloon angioplasty of the left anterior gluteal artery (CSI 1.25 device, 3 mm balloon).
4. Rotational atherectomy and angioplasty of the left posterior gluteal artery (CSI 1.25 mm, 3 mm balloon).
5. Rotational arthrectomy and balloon angioplasty of the left hypogastric artery (CSI 1.25 mm, 5 mm balloon).
SURGEON: Xxxx Xxxxx, MD
ANESTHESIA: Local with moderate sedation.
EBL: Minimal.
COMPLICATIONS: None.
RADIOLOGIC FINDINGS:
1. The abdominal aorta was patent with solitary renal arteries bilaterally. On the right side there appeared to be a greater than 70% right renal artery stenosis. On the left side, the renal artery appeared to bifurcate immediately, or there were possibly 2 left renal arteries with origins very near each other.
The abdominal aorta in the infrarenal position was moderately to severely diseased with atherosclerosis and an ulcerated area was noted on the left anterolateral side wall of the abdominal aorta. That or this was a small pseudoaneurysm off the anterolateral side wall of the abdominal aorta.
Both common iliac arteries were patent with no hemodynamically significant stenosis noted. Both external iliac arteries were also patent with no hemodynamically significant stenosis noted. The right hypogastric artery was patent. The left hypogastric artery had a 50% stenosis at its origin. This branched into the anterior and posterior gluteal arteries, both of which had very significant appearing strictures of greater than 80%.
On the right side, the common femoral artery was patent. The superficial femoral and profunda femoris arteries were patent. The profundus femoris artery had an area of 50 to 60% stenosis approximately 8 cm from its origin. The SFA had a stenosis approximately 10 cm from its origin, which was approximately 70 to 80% stenotic.
The SFA had diffuse disease and gave rise to a popliteal artery which had 50 to 60% stenosis in the above to mid popliteal artery. The popliteal artery below the knee was patent. This then gave rise to very small appearing tibial arteries. The posterior tibial artery was the dominant artery on the right. The anterior tibial artery was also patent and the peroneal artery was also patent.
On the left side, the common femoral artery had approximately 40% stenosis. The profunda femoris artery was patent and the superficial femoral artery was patent. The popliteal artery was patent. This gave rise to posterior tibial and peroneal arteries, of which the posterior tibial artery was the dominant artery. The anterior tibial artery was not well visualized.
I was able to selectively catheterize the right superficial femoral artery and the lesion was treated with first rotational arthrectomy using a CSI 2 mm device at low, medium, and high speeds and this was followed by a balloon angioplasty. A 6 mm x 60 mm Sterling balloon was used and completion arteriogram showed significant improvement of the lesion with approximately 25% residual stenosis. Thus the run off was significantly improved.
After selectively catheterizing the left hypogastric artery from the left side, I determined that the right-sided approach would be better, and so a right-sided access was obtained. The left hypogastric artery, left anterior gluteal artery, and left posterior gluteal artery were selectively catheterized, treated with rotational arthrectomy and given balloon angioplasty. The posterior gluteal artery did not have a very good result. The anterior tibial artery had a residual of less than 30% stenosis and flow was significantly improved in the hypogastric artery following arthrectomy angioplasty. A 5 mm balloon was used in the hypogastric artery as noted above and 3 mm balloons were used in the gluteal arteries.
There were no complications. Upon completion, Angio-Seals were used bilaterally. Number 6 French access was used bilaterally.
PROCEDURE REPORT: The patient was taken to the cardiac catheterization laboratory where she was placed on the table in a dorsal recumbent position. After excellent induction with moderate sedation, the skin of the groin areas were prepped and draped in a standard sterile fashion. I then called a time-out for the correct patient and procedural identification per Xxxxxxx Hospital protocol. Under local anesthesia, I accessed the left common femoral artery in the retrograde direction using ultrasound guidance and a micropuncture needle. The needle accessed easily into the artery and the 0.01 inch guide wire advanced easily into the artery. Over the guide wire, a 5 French sheath was inserted. Through the 5 French sheath, an Omni Flush catheter was inserted and positioned to the L1-L2 vertebral body level, at which point the guide wire was removed, both were removed from the catheter and an AP angiogram of the abdominal aorta was obtained. I also administered 3000 units of unfractionated heparin IV at this time.
I then pulled the catheter down to the aortic bifurcation where oblique images of the iliofemoral and pelvic runoff were obtained. Next, maintaining the catheter in the distal abdominal aorta, a bolus chase angiogram of both lower extremities was performed.
I then selectively catheterized the right superficial femoral artery from the left side and additional images of the right leg and calf were obtained to further elucidate the runoff on the right.
I placed a stiff wire in the right superficial femoral artery and then over the stiff wire, a 6 French Balkan sheath were inserted up and over the aortic bifurcation. The guide wire was exchanged over a catheter for a viper wire and a total of 70 mg per kg of heparin IV was administered. Next, a CSI device measuring 2 mm in diameter was used to treat the right superficial femoral artery lesion at low, medium, and high speeds. A 6 mm x 4 cm angioplasty balloon was then used to post dilate the lesion at 3 atmospheres for 2 minutes. The completion arteriogram showed significant improvement in the lesion. I accepted this result. Next, I selectively catheterized the left hypogastric artery from the right and obtained several additional images of the left hypogastric artery on different planes to better elucidate the lesions there. I decided that the angle into the hypogastric artery was quite steep from the left side and that a right-sided puncture was going to be required to treat these arteries. Thus, again using local anesthesia and ultrasound guidance, I accessed the right common femoral artery. The 6 French sheath was removed from the left side and an Angio-Seal device was deployed. The 5 French sheath in the right groin was then exchanged for the 6 French Balkan sheath. I selectively catheterized the right common femoral artery from the left with a guide wire and then inserted the Balkan up and over the aortic bifurcation. Next I used a comfy catheter in conjunction with a glidewire to selectively catheterize the left hypogastric artery. Using a PT Graphix wire, I was able to cross into the posterior gluteal artery. I was able to advance the sheath over the Comfy catheter and wire and into the left hypogastric artery. Next the Comfy catheter was removed and a CSI 1.25 mm device was used to treat the left posterior gluteal artery at low speed for 30 seconds. This was repeated 3 additional times with interval breaks to allow for clearance of the microscopic debris created by the device.
I then selected a 3 mm angioplasty balloon and used this to post dilate the artery. The artery was noted to be quite resistant to angioplasty and a significant "waist" was noted in the 3 mm balloon which popped at 10 atmospheres. Balloon angioplasty persisted for 2 minutes and the 3 mm balloon was deflated and a completion angiogram was performed. There still appeared to be residual of 25 to 30% or more stenosis in the artery, so a 2nd angioplasty was performed with a similar result.
I then selectively catheterized the anterior tibial artery and exchanged a crossing wire for the viper wire. The anterior tibial artery stenosis was then treated at low speed x4 followed by medium speed x1; 25 to 30 second treatments were performed followed by 25 to 30 second intervals of rest to allow for clearance of the debris. The 3 mm x 2 cm balloon was again used to treat the anterior gluteal artery lesion. A 2-minute inflation was performed and full effacement of the balloon was noted. Completion imaging showed improvement of the anterior and posterior gluteal arteries. The left hypogastric artery was also treated in its origin with the 1.25 mm device at medium and high speeds. A 5 cm x 4 cm angioplasty balloon was used to perform balloon angioplasty here and full effacement of the balloon was noted. The balloon angioplasty persisted for 2 minutes and upon deflation completion angiogram showed improvement of flow into the left hypogastric region.
I accepted this result. An Angio-Seal device was then deployed in the right femoral position. There were no complications and Ms. Xxxx tolerated the procedure well. The sponge and needle counts following the case were correct x2.