rparikh
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Need help with codes : I have 75625-26, 75716-26, 36247-59, 36248-59, 37221-LT,37223-LT,37224-RT,75774-26
PROCEDURES PERFORMED:
1. Abdominal aortography.
2. Selective angiography of the right common iliac artery (cannulation
from contralateral side).
3. Selective angiography of the right external iliac artery
(cannulation from contralateral side).
4. Selective angiography of the right common femoral artery
(cannulation from contralateral side).
5. Right lower extremity runoff angiogram.
6. Selective angiography of the left common iliac artery (cannulation
from ipsilateral side).
7. Selective angiography of the left external iliac artery (cannulation
from ipsilateral side).
8. Selective angiography of the left common femoral artery (cannulation
from the ipsilateral side) with left lower extremity runoff angiogram.
9. Previous PTA (percutaneous transluminal angioplasty) and stenting of
the bilateral SFA (superficial femoral artery) and iliac arteries.
OPERATIVE FINDINGS:
ABDOMINAL AORTOGRAPHY: The abdominal aortogram demonstrates normal
caliber abdominal aorta. There is diffuse atherosclerosis of the distal
abdominal aorta and proximal iliac arteries. The right common iliac
artery is widely patent. The right external iliac artery demonstrates
70% eccentric stenosis. The right common femoral artery is patent. The
right superficial femoral artery is 100% proximally occluded (flush
occluded at its origin). The stents within the right SFA are completely
occluded. The right profunda femoris artery demonstrates a 90-99%
stenosis at its origin. This vessel supplies extensive collaterals to
the distal SFA and the rest of the right leg. The right leg seems to
fill from collaterals via this vessel.
SELECTIVE RIGHT COMMON ILIAC ARTERY ANGIOGRAPHY: The right common iliac
artery demonstrates no significant disease. The external iliac artery
demonstrates 70% eccentric stenosis. There is peak to peak pressure
gradient around 30 mmHg across this lesion. The right profunda femoris
artery is patent. The right superficial femoral artery is 100% occluded
in its proximal segment at the origin of the stents. The right profunda
femoris artery demonstrates an eccentric ostial 90-99% stenosis and this
vessel supplies collaterals to the left leg.
SELECTIVE RIGHT EXTERNAL ILIAC ARTERY ANGIOGRAPHY: External iliac
artery angiogram demonstrates 70% eccentric stenosis. The right common
femoral artery is widely patent. The SFA is 100% occluded. The right
profunda femoris artery demonstrates 90-99% stenosis at its origin.
LEFT COMMON ILIAC ARTERY ANGIOGRAPHY: Left common iliac artery
angiogram demonstrates 50-70% eccentric stenosis. The left external
iliac artery demonstrates 70-80% eccentric stenosis. There is 50 mm
peak to peak systolic pressure gradient across the lesion. The left
common femoral artery is patent. Left profunda femoris artery is patent
and supplies extensive collaterals to the distal SFA. The left
superficial femoral artery is 100% occluded in its proximal and mid
segments. There is 3 vessel runoff in the left leg.
RIGHT LOWER EXTREMITY RUNOFF ANGIOGRAM: Demonstrates occlusion of the
right superficial femoral artery. The profunda femoris artery supplies
collaterals. There is 3 vessel runoff in the right leg. There is
sluggish flow of contrast in the infrapopliteal vessels as a result of
severe occlusion of the right SFA and the severe stenosis in the origin
of the right profunda femoris artery.
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY OF THE RIGHT PROFUNDA FEMORIS
ARTERY: 90-99% stenosis reduced to a residual of 30%. There was
significant improved flow in the profunda femoris and in the collaterals
down the right leg after the initial balloon PTA. No stents were used.
A 6 x 40 mm AngioSculpt balloon was used for the PTA of the origin of
the profunda femoris artery.
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA) OF THE RIGHT EXTERNAL ILIAC
ARTERY: 70% stenosis reduced to a residual around 20-30%. There was
nice flow down the right leg after the PTA of the right external iliac
and the right profunda femoris arteries.
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY/STENTING OF THE LEFT EXTERNAL
ILIAC AND LEFT COMMON FEMORAL ARTERIES: There was 50-60% residual
stenosis of the left external iliac artery after initial balloon PTA. A
9 x 80 mm self-expanding stent was deployed in the left external iliac
and left common iliac arteries. The stent was post-dilated with 7 x 80
mm NC balloon up to 15 atmospheres. There was nice flow down the left
lower extremity after the initial PTA and stenting of the left external
and common iliac arteries.
INDICATIONS AND BRIEF HISTORY:
The patient is a 67-year-old white gentleman with severe bilateral
peripheral artery disease. He has previous PTA and stents of the
superficial femoral and iliac arteries on both sides. He is on Plavix
and aspirin. He continues to smoke. He has multiple risk factors
including diabetes, hypertension, dyslipidemia. The patient comes in
with severe pain in both the calves with resting pain in the right lower
extremity. He has poorly palpable pulses in his legs and clear evidence
of arterial ischemia. The patient was advised peripheral angiography
with revascularization. All the risks and benefits were discussed. A
written informed consent has been obtained.
DESCRIPTION OF PROCEDURE:
Both the groins prepped and draped in the usual sterile fashion.
Lidocaine 1% was infiltrated in the skin and subcutaneous tissue of the
left groin for local anesthesia. A 6 French sheath was placed in the
left femoral artery using modified Seldinger technique. An abdominal
aortogram was performed using a short pigtail catheter. DSA was used.
Nonionic contrast 25 mL was power injected at a rate of 15 mL per
second. The same pigtail catheter was used to cannulate the right
common iliac artery. An Advantage Glidewire was advanced down into the
right lower extremity arteries. The pigtail catheter was then advanced
over the glide catheter into the right common femoral and external iliac
arteries. Selective angiograms were performed in the right common
iliac, right external iliac and the right common femoral arteries.
Right lower extremity angiograms were performed, all the way to the
distal portion of the right leg. There was 3-vessel runoff seen in the
right leg.
The short pigtail catheter was then exchanged out over the Advantage
Glidewire. We advanced a 45 cm long Destination Terumo sheath to the
right external iliac artery. A 0.018 inch x 300 cm long V18 wire was
passed down the right profunda femoris artery. We performed balloon PTA
of the origin of the right profunda femoris artery with a 6 x 40 mm
angioscope balloon. Several balloon inflations were performed. There
was 20-30% residual stenosis after the initial balloon PTA. The vessel
appeared to be widely patent. The same angioscope balloon was used to
perform balloon PTA of the right common femoral and right external iliac
arteries. The 50-70% lesions in both locations were treated adequately.
There was 10-20% residual stenosis in each location.
The patient received a 5000 unit bolus of unfractionated heparin at the
start of the angioplasty procedure (after the sheath delivery to the
right side).
The 45 cm long the Destination sheath was retracted into the left
external iliac artery. There was a 50 mm peak-to-peak systolic pressure
gradient across the lesion in the left common iliac and left external
iliac arteries. We performed balloon PTA with a 5 x 16 mm
semi-compliant balloon. There was 50% residual stenosis in each of
these locations after the initial balloon dilatations. The lesion was
stented with a 7 x 80 mm self-expanding stent. Both lesions were
stented successfully. The lesions in both arteries were then stented
with a 9 x 80 mm self-expanding Abbott stent. After stent deployment
the stent was post-dilated with a 7 x 80 mm NC balloon. Several balloon
inflations were performed at maximum inflation pressure of 15
atmospheres. There was no residual stenosis. No complications.
The patient received a total of around 280 mL of nonionic contrast.
Total fluoroscopy time was 15 minutes. We performed complete left lower
extremity runoff angiograms after the initial stent procedure. A short
7 French sheath was inserted over a wire after exchanging out the
Pinnacle sheath. No groin complications were seen. The ACT was 2:1
seconds at the end of the case.
RECOMMENDATIONS:
1. Remove the sheath.
2. Discharge the patient home today if stable.
3. The patient needs bilateral lower extremity femoral popliteal bypass
surgery. The patient will referred to vascular surgery
Thank You
PROCEDURES PERFORMED:
1. Abdominal aortography.
2. Selective angiography of the right common iliac artery (cannulation
from contralateral side).
3. Selective angiography of the right external iliac artery
(cannulation from contralateral side).
4. Selective angiography of the right common femoral artery
(cannulation from contralateral side).
5. Right lower extremity runoff angiogram.
6. Selective angiography of the left common iliac artery (cannulation
from ipsilateral side).
7. Selective angiography of the left external iliac artery (cannulation
from ipsilateral side).
8. Selective angiography of the left common femoral artery (cannulation
from the ipsilateral side) with left lower extremity runoff angiogram.
9. Previous PTA (percutaneous transluminal angioplasty) and stenting of
the bilateral SFA (superficial femoral artery) and iliac arteries.
OPERATIVE FINDINGS:
ABDOMINAL AORTOGRAPHY: The abdominal aortogram demonstrates normal
caliber abdominal aorta. There is diffuse atherosclerosis of the distal
abdominal aorta and proximal iliac arteries. The right common iliac
artery is widely patent. The right external iliac artery demonstrates
70% eccentric stenosis. The right common femoral artery is patent. The
right superficial femoral artery is 100% proximally occluded (flush
occluded at its origin). The stents within the right SFA are completely
occluded. The right profunda femoris artery demonstrates a 90-99%
stenosis at its origin. This vessel supplies extensive collaterals to
the distal SFA and the rest of the right leg. The right leg seems to
fill from collaterals via this vessel.
SELECTIVE RIGHT COMMON ILIAC ARTERY ANGIOGRAPHY: The right common iliac
artery demonstrates no significant disease. The external iliac artery
demonstrates 70% eccentric stenosis. There is peak to peak pressure
gradient around 30 mmHg across this lesion. The right profunda femoris
artery is patent. The right superficial femoral artery is 100% occluded
in its proximal segment at the origin of the stents. The right profunda
femoris artery demonstrates an eccentric ostial 90-99% stenosis and this
vessel supplies collaterals to the left leg.
SELECTIVE RIGHT EXTERNAL ILIAC ARTERY ANGIOGRAPHY: External iliac
artery angiogram demonstrates 70% eccentric stenosis. The right common
femoral artery is widely patent. The SFA is 100% occluded. The right
profunda femoris artery demonstrates 90-99% stenosis at its origin.
LEFT COMMON ILIAC ARTERY ANGIOGRAPHY: Left common iliac artery
angiogram demonstrates 50-70% eccentric stenosis. The left external
iliac artery demonstrates 70-80% eccentric stenosis. There is 50 mm
peak to peak systolic pressure gradient across the lesion. The left
common femoral artery is patent. Left profunda femoris artery is patent
and supplies extensive collaterals to the distal SFA. The left
superficial femoral artery is 100% occluded in its proximal and mid
segments. There is 3 vessel runoff in the left leg.
RIGHT LOWER EXTREMITY RUNOFF ANGIOGRAM: Demonstrates occlusion of the
right superficial femoral artery. The profunda femoris artery supplies
collaterals. There is 3 vessel runoff in the right leg. There is
sluggish flow of contrast in the infrapopliteal vessels as a result of
severe occlusion of the right SFA and the severe stenosis in the origin
of the right profunda femoris artery.
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY OF THE RIGHT PROFUNDA FEMORIS
ARTERY: 90-99% stenosis reduced to a residual of 30%. There was
significant improved flow in the profunda femoris and in the collaterals
down the right leg after the initial balloon PTA. No stents were used.
A 6 x 40 mm AngioSculpt balloon was used for the PTA of the origin of
the profunda femoris artery.
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA) OF THE RIGHT EXTERNAL ILIAC
ARTERY: 70% stenosis reduced to a residual around 20-30%. There was
nice flow down the right leg after the PTA of the right external iliac
and the right profunda femoris arteries.
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY/STENTING OF THE LEFT EXTERNAL
ILIAC AND LEFT COMMON FEMORAL ARTERIES: There was 50-60% residual
stenosis of the left external iliac artery after initial balloon PTA. A
9 x 80 mm self-expanding stent was deployed in the left external iliac
and left common iliac arteries. The stent was post-dilated with 7 x 80
mm NC balloon up to 15 atmospheres. There was nice flow down the left
lower extremity after the initial PTA and stenting of the left external
and common iliac arteries.
INDICATIONS AND BRIEF HISTORY:
The patient is a 67-year-old white gentleman with severe bilateral
peripheral artery disease. He has previous PTA and stents of the
superficial femoral and iliac arteries on both sides. He is on Plavix
and aspirin. He continues to smoke. He has multiple risk factors
including diabetes, hypertension, dyslipidemia. The patient comes in
with severe pain in both the calves with resting pain in the right lower
extremity. He has poorly palpable pulses in his legs and clear evidence
of arterial ischemia. The patient was advised peripheral angiography
with revascularization. All the risks and benefits were discussed. A
written informed consent has been obtained.
DESCRIPTION OF PROCEDURE:
Both the groins prepped and draped in the usual sterile fashion.
Lidocaine 1% was infiltrated in the skin and subcutaneous tissue of the
left groin for local anesthesia. A 6 French sheath was placed in the
left femoral artery using modified Seldinger technique. An abdominal
aortogram was performed using a short pigtail catheter. DSA was used.
Nonionic contrast 25 mL was power injected at a rate of 15 mL per
second. The same pigtail catheter was used to cannulate the right
common iliac artery. An Advantage Glidewire was advanced down into the
right lower extremity arteries. The pigtail catheter was then advanced
over the glide catheter into the right common femoral and external iliac
arteries. Selective angiograms were performed in the right common
iliac, right external iliac and the right common femoral arteries.
Right lower extremity angiograms were performed, all the way to the
distal portion of the right leg. There was 3-vessel runoff seen in the
right leg.
The short pigtail catheter was then exchanged out over the Advantage
Glidewire. We advanced a 45 cm long Destination Terumo sheath to the
right external iliac artery. A 0.018 inch x 300 cm long V18 wire was
passed down the right profunda femoris artery. We performed balloon PTA
of the origin of the right profunda femoris artery with a 6 x 40 mm
angioscope balloon. Several balloon inflations were performed. There
was 20-30% residual stenosis after the initial balloon PTA. The vessel
appeared to be widely patent. The same angioscope balloon was used to
perform balloon PTA of the right common femoral and right external iliac
arteries. The 50-70% lesions in both locations were treated adequately.
There was 10-20% residual stenosis in each location.
The patient received a 5000 unit bolus of unfractionated heparin at the
start of the angioplasty procedure (after the sheath delivery to the
right side).
The 45 cm long the Destination sheath was retracted into the left
external iliac artery. There was a 50 mm peak-to-peak systolic pressure
gradient across the lesion in the left common iliac and left external
iliac arteries. We performed balloon PTA with a 5 x 16 mm
semi-compliant balloon. There was 50% residual stenosis in each of
these locations after the initial balloon dilatations. The lesion was
stented with a 7 x 80 mm self-expanding stent. Both lesions were
stented successfully. The lesions in both arteries were then stented
with a 9 x 80 mm self-expanding Abbott stent. After stent deployment
the stent was post-dilated with a 7 x 80 mm NC balloon. Several balloon
inflations were performed at maximum inflation pressure of 15
atmospheres. There was no residual stenosis. No complications.
The patient received a total of around 280 mL of nonionic contrast.
Total fluoroscopy time was 15 minutes. We performed complete left lower
extremity runoff angiograms after the initial stent procedure. A short
7 French sheath was inserted over a wire after exchanging out the
Pinnacle sheath. No groin complications were seen. The ACT was 2:1
seconds at the end of the case.
RECOMMENDATIONS:
1. Remove the sheath.
2. Discharge the patient home today if stable.
3. The patient needs bilateral lower extremity femoral popliteal bypass
surgery. The patient will referred to vascular surgery
Thank You