amym
Guest
Is it appropriate to bill this procedure as 37225, 75716-26, 75625-26 or am I missing something?
PROCEDURE PERFORMED:
1. Bilateral selective femoropopliteal and intrapopliteal angiography.
2. PTA of the right SFA.
3. TurboHawk atherectomy of the right popliteal artery.
CHIEF COMPLAINT:
Severe bilateral claudication in this patient with know peripheral
arterial disease and coronary artery disease who presented who after
having stenting to the left SFA he was noted to have severe occlusive
disease below the knee and high-grade stenosis of the SFA bilaterally.
After his stenting of the left SFA significant improvement in his pain
was noted in his left leg by opening the inflow, following which now he
presents to have significant claudication in the right leg, which
remains.
PROTOCOL: The patient was brought to the endovascular lab and prepped
and draped in the usual sterile fashion. Xylocaine was infiltrated and
both groins were prepped. The left femoral artery was cannulated
without difficulty and a J-wire was advanced and an OmniFlush 5-French
catheter was used to advance a Stiff glidewire was used to cross over to
the contralateral side. At this point, using the left femoral sheath,
angiography of the left popliteal artery was performed all the way to
the popliteal artery and it was noted to be the left SFA stent is widely
patent with good flow, however, the flow was slower due to significant
occlusive intrapopliteal disease.
After the identification, a 7-French Pinnacle Destination sheath was
then advanced and crossed over to the contralateral side with placement
of the tip at the contralateral femoral artery and at this point images
were performed and showed multiple areas of stenosis in the SFA on the
right side. The proximal third of the lesion was 50 to 60%, the middle
third the lesion was 60 to 70% and the distal third lesion was 90%.
Immediately below the SFA, the popliteal artery had a focal discrete 90%
stenosis, which was leading up to having a disease trifurcation with
occlusive disease involving all three intrapopliteal vessels with
collateral network, which was faint.
After lesions were identified, it was felt the most appropriate approach
would be a TurboHawk atherectomy involving these two lesions. At this
point, 0.014 Spartacore wire was then advanced and the lesion was
crossed and the wire tip was placed above the trifurcation and the Ellis
TurboHawk catheter was advanced but at the level of the distal third
where there was severe stenosis of the SFA, the TurboHawk could not be
advanced and therefore was removed. At this point, a 4 x 80 Ampherion
Medtronic balloon was then advanced and dilated to 6 atmospheres and
full extension was noted. This was a calcified lesion. After two
balloon inflations, marked improvement was noted up to a maximum of 6
atmospheres with no residual narrowing. There is thrombus or
dissection. There was a mild residual narrowing present. The balloon
was removed and the Turbo Hawk catheter was now successfully advanced
into the popliteal artery stenosis, which was treated with multiple
passes of TurboHawk atherectomy. Two separate runs were done and a
large amount of plaque was removed, revealing smooth margins and an
excellent flow with only then 20% residual narrowing at this lesion site
and at that point, imaging of the intrapopliteal vessels shows no
changes in anatomy. At this point the entire assembly was removed and
ProGlide Perclose device was used for closure, which was successful and
no complications occurred. Final pulses interrogated with Doppler in
both dorsalis pedis, which were unchanged prior to the start of the
procedure.
IMPRESSION:
1. SUCCESSFUL PTA OF THE DISTAL THIRD OF THE SFA USING 4 X 80 AMPHERION
BALLOON WITH A STENOSIS REDUCTION FROM 90% TO LESS THAN 20%.
2. SUCCESSFUL TURBOHAWK ATHERECTOMY OF THE RIGHT POPLITEAL ARTERY WITH
MULTIPLE PASSES USING ELLIS DEVICE WITH LESION REDUCTION FROM 90% TO
LESS THAN 20% WITH ATHERECTOMY ALONE.
Thanks.
PROCEDURE PERFORMED:
1. Bilateral selective femoropopliteal and intrapopliteal angiography.
2. PTA of the right SFA.
3. TurboHawk atherectomy of the right popliteal artery.
CHIEF COMPLAINT:
Severe bilateral claudication in this patient with know peripheral
arterial disease and coronary artery disease who presented who after
having stenting to the left SFA he was noted to have severe occlusive
disease below the knee and high-grade stenosis of the SFA bilaterally.
After his stenting of the left SFA significant improvement in his pain
was noted in his left leg by opening the inflow, following which now he
presents to have significant claudication in the right leg, which
remains.
PROTOCOL: The patient was brought to the endovascular lab and prepped
and draped in the usual sterile fashion. Xylocaine was infiltrated and
both groins were prepped. The left femoral artery was cannulated
without difficulty and a J-wire was advanced and an OmniFlush 5-French
catheter was used to advance a Stiff glidewire was used to cross over to
the contralateral side. At this point, using the left femoral sheath,
angiography of the left popliteal artery was performed all the way to
the popliteal artery and it was noted to be the left SFA stent is widely
patent with good flow, however, the flow was slower due to significant
occlusive intrapopliteal disease.
After the identification, a 7-French Pinnacle Destination sheath was
then advanced and crossed over to the contralateral side with placement
of the tip at the contralateral femoral artery and at this point images
were performed and showed multiple areas of stenosis in the SFA on the
right side. The proximal third of the lesion was 50 to 60%, the middle
third the lesion was 60 to 70% and the distal third lesion was 90%.
Immediately below the SFA, the popliteal artery had a focal discrete 90%
stenosis, which was leading up to having a disease trifurcation with
occlusive disease involving all three intrapopliteal vessels with
collateral network, which was faint.
After lesions were identified, it was felt the most appropriate approach
would be a TurboHawk atherectomy involving these two lesions. At this
point, 0.014 Spartacore wire was then advanced and the lesion was
crossed and the wire tip was placed above the trifurcation and the Ellis
TurboHawk catheter was advanced but at the level of the distal third
where there was severe stenosis of the SFA, the TurboHawk could not be
advanced and therefore was removed. At this point, a 4 x 80 Ampherion
Medtronic balloon was then advanced and dilated to 6 atmospheres and
full extension was noted. This was a calcified lesion. After two
balloon inflations, marked improvement was noted up to a maximum of 6
atmospheres with no residual narrowing. There is thrombus or
dissection. There was a mild residual narrowing present. The balloon
was removed and the Turbo Hawk catheter was now successfully advanced
into the popliteal artery stenosis, which was treated with multiple
passes of TurboHawk atherectomy. Two separate runs were done and a
large amount of plaque was removed, revealing smooth margins and an
excellent flow with only then 20% residual narrowing at this lesion site
and at that point, imaging of the intrapopliteal vessels shows no
changes in anatomy. At this point the entire assembly was removed and
ProGlide Perclose device was used for closure, which was successful and
no complications occurred. Final pulses interrogated with Doppler in
both dorsalis pedis, which were unchanged prior to the start of the
procedure.
IMPRESSION:
1. SUCCESSFUL PTA OF THE DISTAL THIRD OF THE SFA USING 4 X 80 AMPHERION
BALLOON WITH A STENOSIS REDUCTION FROM 90% TO LESS THAN 20%.
2. SUCCESSFUL TURBOHAWK ATHERECTOMY OF THE RIGHT POPLITEAL ARTERY WITH
MULTIPLE PASSES USING ELLIS DEVICE WITH LESION REDUCTION FROM 90% TO
LESS THAN 20% WITH ATHERECTOMY ALONE.
Thanks.