jlb102780
Guru
Hi Coders,
This PV case has me stumped.
37221
75630-26,59
What's stumping me is the femoral part of this case. HELP
PROCEDURE PERFORMED
1. Abdominal aortogram with runoff.
2. Implantation of two overlapping 6.0 mm Omni Link bare metal balloon
expandable peripheral stents into the proximal, mid and distal right
external iliac artery.
3. PTA (balloon angioplasty) of the mid to distal right superficial femoral
artery.
4. Second order catheter placement.
HISTORY
The patient is a very pleasant 61-year-old female who has a long extensive
history of cigarette smoking. She has been experiencing significant
claudication symptoms in both legs. She had some ABI's performed as an
outpatient which were very abnormal. Her ABI was approximately 0.5 on both
sides. She is subsequently referred for an abdominal aortogram with runoffs.
PROCEDURE DETAILS
The patient was brought to the cardiac catheterization laboratory in very
stable condition. Both groins were carefully prepped and draped in a sterile
fashion. Using 1% Xylocaine, the left femoral artery was anesthetized.
Using a Cook needle, the left femoral artery was entered without any
difficulty and a 5-French sheath was inserted via Seldinger technique. The
sheath was aspirated and flushed. A 5-French pigtail catheter was then
advanced in the patient's abdominal aorta. Initial abdominal aortogram was
performed with pigtail catheter being placed at the level of the first lumbar
vertebrae. The pigtail catheter was then pulled down just above the aortic
bifurcation. A second abdominal aortogram was performed in order to
evaluate the iliac arteries more carefully as well as the femoral arteries.
A second abdominal aortogram with runoffs was performed to evaluate the
distal circulation in both legs. All these abdominal aortograms were
performed utilizing digital subtraction angiography.
The patient was found to have significant obstructive narrowing present in
the very proximal right common iliac artery as well as the right external
iliac artery. Additionally, the right superficial femoral artery was
severely diseased and totally occluded distally. There was extensive
collateralization noted to the distal right superficial femoral artery and
right popliteal artery. Below the patient's right knee, there was single
vessel runoff noted. There were extensive collaterals noted below the knee
as well. On the left side, the iliac arteries were patent. There was a long
area of severe disease present in the mid to distal left superficial femoral
artery. Below the patient's left knee, there was single vessel runoff in the
patient's left foot noted. There were extensive collaterals noted below the
left knee as well.
Upon reviewing the patient's cineangiograms, and since we had already stuck
her from the left groin, I felt the best course of action would be to
intervene on the disease in the right external iliac artery. After
intervening on that, I felt that we could then try to advance her sheath down
stream and work on the patient's totally occluded right superficial femoral
artery. I could not do anything with the proximal right common iliac artery
lesion as I could not intervene on this from the left groin.
My plan was then to bring the patient back electively and from the right
groin intervene on the patient's left superficial femoral artery and then on
the way out fix the right common iliac artery lesion.
I next took a 4-French multipurpose catheter and advanced it into the
patient's aorta over a J-wire. The J-wire was removed. We then pulled the
6-French multipurpose catheter back to make sure that there was no evidence
of significant obstructive narrowing present in the distal abdominal aorta.
There was some mild tapering noted in the distal abdominal aorta and I wanted
to make sure there was no evidence of any narrowing that was hemodynamically
significant. We pulled the 4-French multipurpose catheter back slowly and
documented there was no significant pressure gradient measured in the distal
abdominal aorta extending into the left iliac artery.
We then switched out over a J-wire for a 5-French IM diagnostic catheter.
Utilizing an angled Glide wire I was able to manipulate the 5-French IM
coronary diagnostic catheter down the patient's left superficial femoral
artery and exchanged out for a conventional J-wire. The J-wire was placed
into the mid left superficial femoral artery. The IM catheter was then
removed over the J-wire. I then exchanged out the sheath for a 6-French
Terumo destination sheath. The tip of the Terumo destination sheath was
advanced around the aortic bifurcation down into the distal right common
iliac artery. We removed the sheath. We performed cineangiogram and
documented there appeared to be some evidence of spasm in the right external
iliac artery. At this point in time, the patient was given 3000 units of
intravenous heparin. She was also given 300 mcg of intracoronary
nitroglycerin as well.
Subsequent cineangiograms revealed some improvement. I felt we could now
start to perform balloon angioplasty. We selected a 5.0 mm Fox Plus
peripheral balloon catheter, balloon being 40 mm in length. The catheter was
brought down into position. A couple inflations were made in the right
external iliac artery starting at the take-off from the right common iliac
artery. The balloon was then deflated and removed. Subsequent
cineangiograms did reveal significant improvement at the balloon angioplasty
site. I felt we could now place a stent. I selected a 6.0 mm Omni Link
balloon expandable peripheral stent catheter, stent being 39 mm in length.
This stent catheter was brought down into position. We placed in the very
proximal aspect of the stent catheter at the take-off of the patient's right
external iliac artery. I was happy with the position of the stent catheter,
and I inflated the stent catheter very carefully to 11 atmospheres of
pressure and held the balloon inflation for 30 seconds and then deployed the
stent. I then deflated the stent catheter and removed it. Subsequent
angiograms revealed a nice angiographic result at the implantation site. I
felt that we needed to place a second stent more distally. We selected
another 6.0 mm Omni Link balloon expandable peripheral stent catheter. I
brought the stent catheter down into position. This stent was also 39 mm in
length. When I was satisfied with the position, I inflated the stent
catheter to 11 atmospheres of pressure and held the balloon inflation for 20
seconds in order to deploy the stent. We then deflated the stent catheter
and removed it. Subsequent angiograms revealed a nice angiographic result.
The overlapping stented segment appeared to be widely patent. The flow down
the patient's left femoral artery also appeared to be improved. I felt we
should post dilate these stents. We selected a 6.0 mm Ultra Thin Diamond
high pressure angioplasty balloon catheter, the balloon being 6 cm in length.
This balloon catheter was brought down and positioned. Two balloon
inflations were made, working our way from distal to proximal. Each balloon
inflation was 6 atmospheres and held for approximately 30 seconds. We then
deflated the Ultra Thin Diamond peripheral balloon catheter and removed it.
Subsequent angiograms revealed a very nice angiographic result. The
overlapping stented segment was widely patent.
I then carefully advanced the sheath further down stream over the J-wire
after telescoping it over a 4-French multipurpose catheter. We parked the
distal part of the sheath in the most distal part of stent in the right
external iliac artery. Subsequent cineangiograms were then performed. We
documented that the mid right superficial femoral artery was severely
diseased and totally occluded. It filled from collaterals distally. I then
advanced a 4-French Glide catheter down to this area over a J-wire then
angled Glide wire. I was unable to cross the totally occluded area with a
4-French angled or 4-French straight catheter or Glide wire.
At this point in time, we removed the Glide catheter. Final cineangiograms
did show good flow down the vessel. This was felt by the stents we had
placed in the right external iliac artery. We then switched out for a short
conventional sheath, which was a 6-French sheath, in the patient's left
femoral artery. We performed a cineangiogram of the patient's left femoral
artery in the 30 degree LAO projection. We documented sheath insertion site
was above the bifurcation of the patient's left femoral artery. The
patient's left femoral artery was then closed percutaneously with a 6-French
Angio Seal device. Excellent hemostasis was obtained.
The patient tolerated the procedure quite well. There were no complications
during the procedure. She will be hydrated in the COPS unit for a few hours
and then will be discharged later on this afternoon. She will come back next
week electively for an attempt at catheter based intervention on the long
area of severe disease in the left superficial femoral artery. If this is
successful, then on the way out, we will stent the right common iliac artery.
That could not be done today from the left groin. Our long term plan is to
see how she is doing after stopping her cigarette smoking with successful
stenting of her right external and right common iliac artery. If her
claudication symptoms do not improve significantly, then she may require a
right fem-pop bypass graft surgery eventually.
RESULTS OF ANGIOGRAPHY
1. Abdominal aorta displays diffuse plaquing throughout. There is some very
mild tapering noted of the distal abdominal aorta just prior to the
bifurcation of the abdominal aorta into both iliac arteries. There is no
significant pressure gradient measured across this narrowing, however.
2. The right renal artery has a 20-30% obstructive narrowing present in its
proximal aspect. The left renal artery also has mild obstructive narrowing
noted as well.
3. The right common iliac artery has a 70% obstructive narrowing present in
its proximal aspect starting at the take-off from the abdominal aorta.
Further down stream, the right external iliac artery has a long segment of
disease present almost throughout the entire length with a maximum
narrowing of 80% noted. The right femoral artery is patent.
4. The proximal right superficial femoral artery had some mild obstructive
narrowing noted. The proximal right superficial femoral artery is
moderately diseased. The mid right superficial femoral artery is severely
diseased and subsequently totally occluded. There is extensive collateral
filling of the distal right superficial femoral artery noted. The right
popliteal artery is widely patent. Below the patient's right knee, the
right anterior tibial and right posterior tibial arteries are totally
occluded. The right peroneal artery is patent to the patient's right foot.
There is single vessel runoff of the patient's right foot noted.
5. The left common iliac and left external iliac arteries are both widely
patent with mild disease noted. The left femoral artery is widely patent.
6. The left superficial femoral artery has mild disease noted in its
proximal aspect. In the mid to distal left superficial femoral artery,
there is a long segment of disease noted with a maximum narrowing of 95%
noted. The left popliteal artery is diffusely diseased but patent. Below
the patient's left knee, the left anterior tibial artery is patent most of
the way down the left leg but then is totally occluded. The left anterior
tibial and left posterior tibial arteries are both totally occluded. There
is some collateral filling noted of the left posterior tibial artery.
There is single vessel runoff noted and this is via collaterals to the
patient's left foot noted.
7. After successful implantation of two overlapping 6.0 mm Omni Link balloon
expandable peripheral stents into the right external iliac artery, the long
area of disease with maximal narrowing of 80% pre-intervention was reduced
to no narrowing post intervention.
8. After unsuccessful attempt at PTA (balloon angioplasty) of the patient's
mid to distal right superficial femoral artery, the totally occluded mid to
distal right superficial femoral artery pre-intervention remained totally
occluded post intervention.
CONCLUSIONS
1. Mild diffuse plaquing noted in the abdominal aorta with some mild distal
tapering noted as described above. This was not hemodynamically
significant.
2. Mild disease present in both renal arteries.
3. High grade obstructive narrowing present in the proximal aspect of the
right common iliac artery at the take-off from the aorta. There was also
high grade obstructive narrowing present in the right external iliac artery
as well.
4. Severely diseased and totally occluded right superficial femoral artery
with the distal right superficial femoral artery filling well from
collaterals. There is single vessel runoff to the patient's right foot
noted.
5. Mild disease present in the left iliac artery.
6. Long area of severe disease present in the mid to distal left superficial
femoral artery. There is single vessel runoff via collaterals of the
patient's left foot noted.
7. Successful implantation of two overlapping 6.0 mm (39 mm long) Omni Link
balloon expandable bare metal peripheral stents of almost the entire length
of the right external iliac artery starting at the take-off. The long area
of disease with maximal narrowing of 80% pre-intervention was reduced to no
residual narrowing noted post intervention.
8. Unsuccessful attempt at PTA (balloon angioplasty) of the patient's
severely diseased and totally occluded mid to distal right superficial
femoral artery. We were unable to cross the total occlusion with an
angioplasty wire or a Glide catheter. The totally occluded mid to distal
right superficial femoral artery pre-intervention remained totally occluded
post intervention.
9. Successful percutaneous closure of the patient's left femoral artery with
a 6-French Angio Seal device.
10. The patient will be brought back electively next week for attempt at
catheter based intervention first on the left superficial femoral artery
and then subsequently on the right common iliac artery.
This PV case has me stumped.
37221
75630-26,59
What's stumping me is the femoral part of this case. HELP
PROCEDURE PERFORMED
1. Abdominal aortogram with runoff.
2. Implantation of two overlapping 6.0 mm Omni Link bare metal balloon
expandable peripheral stents into the proximal, mid and distal right
external iliac artery.
3. PTA (balloon angioplasty) of the mid to distal right superficial femoral
artery.
4. Second order catheter placement.
HISTORY
The patient is a very pleasant 61-year-old female who has a long extensive
history of cigarette smoking. She has been experiencing significant
claudication symptoms in both legs. She had some ABI's performed as an
outpatient which were very abnormal. Her ABI was approximately 0.5 on both
sides. She is subsequently referred for an abdominal aortogram with runoffs.
PROCEDURE DETAILS
The patient was brought to the cardiac catheterization laboratory in very
stable condition. Both groins were carefully prepped and draped in a sterile
fashion. Using 1% Xylocaine, the left femoral artery was anesthetized.
Using a Cook needle, the left femoral artery was entered without any
difficulty and a 5-French sheath was inserted via Seldinger technique. The
sheath was aspirated and flushed. A 5-French pigtail catheter was then
advanced in the patient's abdominal aorta. Initial abdominal aortogram was
performed with pigtail catheter being placed at the level of the first lumbar
vertebrae. The pigtail catheter was then pulled down just above the aortic
bifurcation. A second abdominal aortogram was performed in order to
evaluate the iliac arteries more carefully as well as the femoral arteries.
A second abdominal aortogram with runoffs was performed to evaluate the
distal circulation in both legs. All these abdominal aortograms were
performed utilizing digital subtraction angiography.
The patient was found to have significant obstructive narrowing present in
the very proximal right common iliac artery as well as the right external
iliac artery. Additionally, the right superficial femoral artery was
severely diseased and totally occluded distally. There was extensive
collateralization noted to the distal right superficial femoral artery and
right popliteal artery. Below the patient's right knee, there was single
vessel runoff noted. There were extensive collaterals noted below the knee
as well. On the left side, the iliac arteries were patent. There was a long
area of severe disease present in the mid to distal left superficial femoral
artery. Below the patient's left knee, there was single vessel runoff in the
patient's left foot noted. There were extensive collaterals noted below the
left knee as well.
Upon reviewing the patient's cineangiograms, and since we had already stuck
her from the left groin, I felt the best course of action would be to
intervene on the disease in the right external iliac artery. After
intervening on that, I felt that we could then try to advance her sheath down
stream and work on the patient's totally occluded right superficial femoral
artery. I could not do anything with the proximal right common iliac artery
lesion as I could not intervene on this from the left groin.
My plan was then to bring the patient back electively and from the right
groin intervene on the patient's left superficial femoral artery and then on
the way out fix the right common iliac artery lesion.
I next took a 4-French multipurpose catheter and advanced it into the
patient's aorta over a J-wire. The J-wire was removed. We then pulled the
6-French multipurpose catheter back to make sure that there was no evidence
of significant obstructive narrowing present in the distal abdominal aorta.
There was some mild tapering noted in the distal abdominal aorta and I wanted
to make sure there was no evidence of any narrowing that was hemodynamically
significant. We pulled the 4-French multipurpose catheter back slowly and
documented there was no significant pressure gradient measured in the distal
abdominal aorta extending into the left iliac artery.
We then switched out over a J-wire for a 5-French IM diagnostic catheter.
Utilizing an angled Glide wire I was able to manipulate the 5-French IM
coronary diagnostic catheter down the patient's left superficial femoral
artery and exchanged out for a conventional J-wire. The J-wire was placed
into the mid left superficial femoral artery. The IM catheter was then
removed over the J-wire. I then exchanged out the sheath for a 6-French
Terumo destination sheath. The tip of the Terumo destination sheath was
advanced around the aortic bifurcation down into the distal right common
iliac artery. We removed the sheath. We performed cineangiogram and
documented there appeared to be some evidence of spasm in the right external
iliac artery. At this point in time, the patient was given 3000 units of
intravenous heparin. She was also given 300 mcg of intracoronary
nitroglycerin as well.
Subsequent cineangiograms revealed some improvement. I felt we could now
start to perform balloon angioplasty. We selected a 5.0 mm Fox Plus
peripheral balloon catheter, balloon being 40 mm in length. The catheter was
brought down into position. A couple inflations were made in the right
external iliac artery starting at the take-off from the right common iliac
artery. The balloon was then deflated and removed. Subsequent
cineangiograms did reveal significant improvement at the balloon angioplasty
site. I felt we could now place a stent. I selected a 6.0 mm Omni Link
balloon expandable peripheral stent catheter, stent being 39 mm in length.
This stent catheter was brought down into position. We placed in the very
proximal aspect of the stent catheter at the take-off of the patient's right
external iliac artery. I was happy with the position of the stent catheter,
and I inflated the stent catheter very carefully to 11 atmospheres of
pressure and held the balloon inflation for 30 seconds and then deployed the
stent. I then deflated the stent catheter and removed it. Subsequent
angiograms revealed a nice angiographic result at the implantation site. I
felt that we needed to place a second stent more distally. We selected
another 6.0 mm Omni Link balloon expandable peripheral stent catheter. I
brought the stent catheter down into position. This stent was also 39 mm in
length. When I was satisfied with the position, I inflated the stent
catheter to 11 atmospheres of pressure and held the balloon inflation for 20
seconds in order to deploy the stent. We then deflated the stent catheter
and removed it. Subsequent angiograms revealed a nice angiographic result.
The overlapping stented segment appeared to be widely patent. The flow down
the patient's left femoral artery also appeared to be improved. I felt we
should post dilate these stents. We selected a 6.0 mm Ultra Thin Diamond
high pressure angioplasty balloon catheter, the balloon being 6 cm in length.
This balloon catheter was brought down and positioned. Two balloon
inflations were made, working our way from distal to proximal. Each balloon
inflation was 6 atmospheres and held for approximately 30 seconds. We then
deflated the Ultra Thin Diamond peripheral balloon catheter and removed it.
Subsequent angiograms revealed a very nice angiographic result. The
overlapping stented segment was widely patent.
I then carefully advanced the sheath further down stream over the J-wire
after telescoping it over a 4-French multipurpose catheter. We parked the
distal part of the sheath in the most distal part of stent in the right
external iliac artery. Subsequent cineangiograms were then performed. We
documented that the mid right superficial femoral artery was severely
diseased and totally occluded. It filled from collaterals distally. I then
advanced a 4-French Glide catheter down to this area over a J-wire then
angled Glide wire. I was unable to cross the totally occluded area with a
4-French angled or 4-French straight catheter or Glide wire.
At this point in time, we removed the Glide catheter. Final cineangiograms
did show good flow down the vessel. This was felt by the stents we had
placed in the right external iliac artery. We then switched out for a short
conventional sheath, which was a 6-French sheath, in the patient's left
femoral artery. We performed a cineangiogram of the patient's left femoral
artery in the 30 degree LAO projection. We documented sheath insertion site
was above the bifurcation of the patient's left femoral artery. The
patient's left femoral artery was then closed percutaneously with a 6-French
Angio Seal device. Excellent hemostasis was obtained.
The patient tolerated the procedure quite well. There were no complications
during the procedure. She will be hydrated in the COPS unit for a few hours
and then will be discharged later on this afternoon. She will come back next
week electively for an attempt at catheter based intervention on the long
area of severe disease in the left superficial femoral artery. If this is
successful, then on the way out, we will stent the right common iliac artery.
That could not be done today from the left groin. Our long term plan is to
see how she is doing after stopping her cigarette smoking with successful
stenting of her right external and right common iliac artery. If her
claudication symptoms do not improve significantly, then she may require a
right fem-pop bypass graft surgery eventually.
RESULTS OF ANGIOGRAPHY
1. Abdominal aorta displays diffuse plaquing throughout. There is some very
mild tapering noted of the distal abdominal aorta just prior to the
bifurcation of the abdominal aorta into both iliac arteries. There is no
significant pressure gradient measured across this narrowing, however.
2. The right renal artery has a 20-30% obstructive narrowing present in its
proximal aspect. The left renal artery also has mild obstructive narrowing
noted as well.
3. The right common iliac artery has a 70% obstructive narrowing present in
its proximal aspect starting at the take-off from the abdominal aorta.
Further down stream, the right external iliac artery has a long segment of
disease present almost throughout the entire length with a maximum
narrowing of 80% noted. The right femoral artery is patent.
4. The proximal right superficial femoral artery had some mild obstructive
narrowing noted. The proximal right superficial femoral artery is
moderately diseased. The mid right superficial femoral artery is severely
diseased and subsequently totally occluded. There is extensive collateral
filling of the distal right superficial femoral artery noted. The right
popliteal artery is widely patent. Below the patient's right knee, the
right anterior tibial and right posterior tibial arteries are totally
occluded. The right peroneal artery is patent to the patient's right foot.
There is single vessel runoff of the patient's right foot noted.
5. The left common iliac and left external iliac arteries are both widely
patent with mild disease noted. The left femoral artery is widely patent.
6. The left superficial femoral artery has mild disease noted in its
proximal aspect. In the mid to distal left superficial femoral artery,
there is a long segment of disease noted with a maximum narrowing of 95%
noted. The left popliteal artery is diffusely diseased but patent. Below
the patient's left knee, the left anterior tibial artery is patent most of
the way down the left leg but then is totally occluded. The left anterior
tibial and left posterior tibial arteries are both totally occluded. There
is some collateral filling noted of the left posterior tibial artery.
There is single vessel runoff noted and this is via collaterals to the
patient's left foot noted.
7. After successful implantation of two overlapping 6.0 mm Omni Link balloon
expandable peripheral stents into the right external iliac artery, the long
area of disease with maximal narrowing of 80% pre-intervention was reduced
to no narrowing post intervention.
8. After unsuccessful attempt at PTA (balloon angioplasty) of the patient's
mid to distal right superficial femoral artery, the totally occluded mid to
distal right superficial femoral artery pre-intervention remained totally
occluded post intervention.
CONCLUSIONS
1. Mild diffuse plaquing noted in the abdominal aorta with some mild distal
tapering noted as described above. This was not hemodynamically
significant.
2. Mild disease present in both renal arteries.
3. High grade obstructive narrowing present in the proximal aspect of the
right common iliac artery at the take-off from the aorta. There was also
high grade obstructive narrowing present in the right external iliac artery
as well.
4. Severely diseased and totally occluded right superficial femoral artery
with the distal right superficial femoral artery filling well from
collaterals. There is single vessel runoff to the patient's right foot
noted.
5. Mild disease present in the left iliac artery.
6. Long area of severe disease present in the mid to distal left superficial
femoral artery. There is single vessel runoff via collaterals of the
patient's left foot noted.
7. Successful implantation of two overlapping 6.0 mm (39 mm long) Omni Link
balloon expandable bare metal peripheral stents of almost the entire length
of the right external iliac artery starting at the take-off. The long area
of disease with maximal narrowing of 80% pre-intervention was reduced to no
residual narrowing noted post intervention.
8. Unsuccessful attempt at PTA (balloon angioplasty) of the patient's
severely diseased and totally occluded mid to distal right superficial
femoral artery. We were unable to cross the total occlusion with an
angioplasty wire or a Glide catheter. The totally occluded mid to distal
right superficial femoral artery pre-intervention remained totally occluded
post intervention.
9. Successful percutaneous closure of the patient's left femoral artery with
a 6-French Angio Seal device.
10. The patient will be brought back electively next week for attempt at
catheter based intervention first on the left superficial femoral artery
and then subsequently on the right common iliac artery.