csorensen21@yahoo.com
Networker
- Messages
- 70
- Best answers
- 0
Not sure how to code this scenario... any help is appreciated.
INDICATION FOR THE PROCEDURE: Bilateral claudication with worse symptoms on the left side. Noninvasive study on previous peripheral angiogram showed total occlusion of the left superficial femoral artery.
PROCEDURES PERFORMED:
1. Peripheral angiogram.
2. Distal abdominal aortogram, bilateral iliofemoral angiogram.
3. Selective right common femoral artery angiogram with runoff.
4. Selective left common femoral artery angiogram with runoff.
5. Multiple segmental angiograms of left lower extremity on DSA mode.
6. Ultrasound-guided left posterior tibial artery access.
7. Successful crossing of the left superficial femoral artery, chronic total occlusion using an Ocelot device to cross the proximal cap and pedal access with a wire and guiding catheter technique to cross the distal cap.
8. Snare of the wire using GooseNeck snare to externalize the wire from the pedal access to the right common femoral artery access site.
9. Successful orbital atherectomy of the left superficial femoral artery using 2.0 CSI device.
10. Successful adjunct balloon angioplasty of the left superficial femoral artery using 4.0 x 300 mm balloon.
11. Mynx closure device.
ESTIMATED AMOUNT OF CONTRAST: 100 mL
ESTIMATED AMOUNT OF BLOOD LOSS: Less than 20 mL.
Sedation was with moderate sedation using Versed and fentanyl in additionto local anesthesia using 1% lidocaine. Total sedation time was 2 hours and 30 seconds.
PROCEDURE NOTE: Informed consent was obtained prior to performing the procedure. The patient was brought to the cardiac catheterization suite postabsorptive, nonsedated state. The right groin was prepped and draped in usual sterile manner, 1% lidocaine was used for infiltration of anesthesia. Using modified Seldinger technique with precision micropuncture sheath, we obtained access to the right common femoral artery. Through the sidearm of the sheath, we performed selective right common femoral artery angiogram with runoff. Following that, we advanced 6-French IMA catheter to distal abdominal aortic position. The catheter was used to perform selective distal abdominal angiogram with bilateral iliofemoral angiogram on DSA mode. Following that, we used a Glide Advantage wire to advance the IMA catheter to the left common femoral artery position. Through the catheter, we performed selective left common femoral artery angiogram with runoff. Multiple segmental angiograms of left lower extremity was performed in DSA mode. After reviewing angiographic results, we decided to intervene on the left chronically and totally occluded superficial femoral artery. The sheath was exchanged over the Glide Advantage wire to 7-French x 45 cm long sheath. Therapeutic doses of heparin were given with documented therapeutic ACTs. Using a run-through wire, we advanced an Ocelot device to the proximal cap of the chronically and totally occluded left superficial femoral artery. Using the Ocelot, we were able to cross the chronically and totally occluded left SFA, all the way to the distal cap. Multiple attempts were tried to cross the distal cap without success. At that point, we decided to go with the pedal access. The left foot was prepped and draped in the usual sterile manner. Using ultrasound guidance, we obtained access with a 4-French sheath to the left posterior tibial artery. Through the sheath, we advanced an 0.018 gold tip glide with an 0.018 Quick-Cross, and we were able to cross the distal cap all the way to the common femoral artery. Using a goose neck snare, we were able to snare the gold tip Glidewire from the left common femoral artery and externalize it from the right common femoral artery sheath. Advancing the 0.018 Quick-Cross from the right common femoral artery access site, we were able to exchange the
wire to CSI wire. Over the CSI wire, we performed orbital atherectomy of the left SFA using CSI device. The sheath in the left posterior tibial artery site was removed and manual pressure was held.
While we were doing adjunct balloon angioplasty of the left SFA using 4-0 x 300 mm pacific balloon. Multiple inflations were done. Repeat angiogram showed excellent result without complications. The wire was removed and then sheath was exchanged to 7-French short sheath. Mynx closure device was used to achieve hemostasis on the right common femoral artery access site. The patient tolerated the procedure well without complications. __ was then transported to post-catheterization area in stable
condition.
ANGIOGRAPHIC FINDINGS:
1. Distal abdominal aorta has minor luminal irregularities.
2. The right common iliac artery has minor luminal irregularities.
3. Right external iliac artery has patent stents with no in-stent restenosis.
4. Right internal iliac artery is aneurysmal.
5. Right common femoral artery has minor luminal irregularities.
6. Right profunda has minor luminal irregularities.
7. Right SFA is patent with minor luminal irregularities. At the distal end, there is an open stent with no in-stent restenosis from his previous procedure.
8. Right popliteal artery has minor luminal irregularities.
9. Right TP trunk has minor luminal irregularities.
10. Right anterior tibial artery has minor luminal irregularities.
11. Right posterior tibial artery has minor luminal irregularities.
12. Right peroneal artery has minor luminal irregularities.
13. Left common iliac artery has minor luminal irregularities.
14. Left internal iliac artery has mild diffuse disease.
15. Left external iliac artery has minor luminal irregularities.
16. Left common femoral artery has minor luminal irregularities.
17. Left profunda artery has minor luminal irregularities.
18. Left external iliac artery has minor luminal irregularities.
19. Left common femoral artery has minor luminal irregularities.
20. Left profunda has minor luminal irregularities.
21. Left SFA has chronic total occlusion from proximal segment with reconstitution of distal segment through collaterals.
22. Left popliteal artery has minor luminal irregularities.
23. Left posterior tibial artery has minor luminal irregularities.
24. Left anterior tibial artery has total occlusion.
25. Left peroneal artery has minor luminal irregularities.
FINAL IMPRESSION:
1. Chronic total occlusion of the left superficial femoral artery, status post successful revascularization using CSI Diamondback device followed by adjunct balloon angioplasty using 4.0 balloon with lesion reduction down to less than 20%.
2. Patent right superficial femoral artery with patent distal stent.
3. Patent right external iliac artery with patent stents.
RECOMMENDATIONS:
1. Continue with aspirin and statin therapy.
2. Aggressive risk factor modifications.
3. Continue with Plavix therapy.
4. IV hydration.
5. Monitoring for 23 hours with possible discharge in the morning to
follow up with me in the office within 1 week.
INDICATION FOR THE PROCEDURE: Bilateral claudication with worse symptoms on the left side. Noninvasive study on previous peripheral angiogram showed total occlusion of the left superficial femoral artery.
PROCEDURES PERFORMED:
1. Peripheral angiogram.
2. Distal abdominal aortogram, bilateral iliofemoral angiogram.
3. Selective right common femoral artery angiogram with runoff.
4. Selective left common femoral artery angiogram with runoff.
5. Multiple segmental angiograms of left lower extremity on DSA mode.
6. Ultrasound-guided left posterior tibial artery access.
7. Successful crossing of the left superficial femoral artery, chronic total occlusion using an Ocelot device to cross the proximal cap and pedal access with a wire and guiding catheter technique to cross the distal cap.
8. Snare of the wire using GooseNeck snare to externalize the wire from the pedal access to the right common femoral artery access site.
9. Successful orbital atherectomy of the left superficial femoral artery using 2.0 CSI device.
10. Successful adjunct balloon angioplasty of the left superficial femoral artery using 4.0 x 300 mm balloon.
11. Mynx closure device.
ESTIMATED AMOUNT OF CONTRAST: 100 mL
ESTIMATED AMOUNT OF BLOOD LOSS: Less than 20 mL.
Sedation was with moderate sedation using Versed and fentanyl in additionto local anesthesia using 1% lidocaine. Total sedation time was 2 hours and 30 seconds.
PROCEDURE NOTE: Informed consent was obtained prior to performing the procedure. The patient was brought to the cardiac catheterization suite postabsorptive, nonsedated state. The right groin was prepped and draped in usual sterile manner, 1% lidocaine was used for infiltration of anesthesia. Using modified Seldinger technique with precision micropuncture sheath, we obtained access to the right common femoral artery. Through the sidearm of the sheath, we performed selective right common femoral artery angiogram with runoff. Following that, we advanced 6-French IMA catheter to distal abdominal aortic position. The catheter was used to perform selective distal abdominal angiogram with bilateral iliofemoral angiogram on DSA mode. Following that, we used a Glide Advantage wire to advance the IMA catheter to the left common femoral artery position. Through the catheter, we performed selective left common femoral artery angiogram with runoff. Multiple segmental angiograms of left lower extremity was performed in DSA mode. After reviewing angiographic results, we decided to intervene on the left chronically and totally occluded superficial femoral artery. The sheath was exchanged over the Glide Advantage wire to 7-French x 45 cm long sheath. Therapeutic doses of heparin were given with documented therapeutic ACTs. Using a run-through wire, we advanced an Ocelot device to the proximal cap of the chronically and totally occluded left superficial femoral artery. Using the Ocelot, we were able to cross the chronically and totally occluded left SFA, all the way to the distal cap. Multiple attempts were tried to cross the distal cap without success. At that point, we decided to go with the pedal access. The left foot was prepped and draped in the usual sterile manner. Using ultrasound guidance, we obtained access with a 4-French sheath to the left posterior tibial artery. Through the sheath, we advanced an 0.018 gold tip glide with an 0.018 Quick-Cross, and we were able to cross the distal cap all the way to the common femoral artery. Using a goose neck snare, we were able to snare the gold tip Glidewire from the left common femoral artery and externalize it from the right common femoral artery sheath. Advancing the 0.018 Quick-Cross from the right common femoral artery access site, we were able to exchange the
wire to CSI wire. Over the CSI wire, we performed orbital atherectomy of the left SFA using CSI device. The sheath in the left posterior tibial artery site was removed and manual pressure was held.
While we were doing adjunct balloon angioplasty of the left SFA using 4-0 x 300 mm pacific balloon. Multiple inflations were done. Repeat angiogram showed excellent result without complications. The wire was removed and then sheath was exchanged to 7-French short sheath. Mynx closure device was used to achieve hemostasis on the right common femoral artery access site. The patient tolerated the procedure well without complications. __ was then transported to post-catheterization area in stable
condition.
ANGIOGRAPHIC FINDINGS:
1. Distal abdominal aorta has minor luminal irregularities.
2. The right common iliac artery has minor luminal irregularities.
3. Right external iliac artery has patent stents with no in-stent restenosis.
4. Right internal iliac artery is aneurysmal.
5. Right common femoral artery has minor luminal irregularities.
6. Right profunda has minor luminal irregularities.
7. Right SFA is patent with minor luminal irregularities. At the distal end, there is an open stent with no in-stent restenosis from his previous procedure.
8. Right popliteal artery has minor luminal irregularities.
9. Right TP trunk has minor luminal irregularities.
10. Right anterior tibial artery has minor luminal irregularities.
11. Right posterior tibial artery has minor luminal irregularities.
12. Right peroneal artery has minor luminal irregularities.
13. Left common iliac artery has minor luminal irregularities.
14. Left internal iliac artery has mild diffuse disease.
15. Left external iliac artery has minor luminal irregularities.
16. Left common femoral artery has minor luminal irregularities.
17. Left profunda artery has minor luminal irregularities.
18. Left external iliac artery has minor luminal irregularities.
19. Left common femoral artery has minor luminal irregularities.
20. Left profunda has minor luminal irregularities.
21. Left SFA has chronic total occlusion from proximal segment with reconstitution of distal segment through collaterals.
22. Left popliteal artery has minor luminal irregularities.
23. Left posterior tibial artery has minor luminal irregularities.
24. Left anterior tibial artery has total occlusion.
25. Left peroneal artery has minor luminal irregularities.
FINAL IMPRESSION:
1. Chronic total occlusion of the left superficial femoral artery, status post successful revascularization using CSI Diamondback device followed by adjunct balloon angioplasty using 4.0 balloon with lesion reduction down to less than 20%.
2. Patent right superficial femoral artery with patent distal stent.
3. Patent right external iliac artery with patent stents.
RECOMMENDATIONS:
1. Continue with aspirin and statin therapy.
2. Aggressive risk factor modifications.
3. Continue with Plavix therapy.
4. IV hydration.
5. Monitoring for 23 hours with possible discharge in the morning to
follow up with me in the office within 1 week.