rparikh
Networker
I am not sure these are the correct codes 75625-26,75710-26,36247,36248,37224 and 37228
PROCEDURES PERFORMED:
1. Digital subtraction angiography of the abdominal and aortoiliac
vessels. ?75625, 75710
2. Selective iliofemoral angiography via contralateral approach.
3. Selective right superficial femoral artery angiography via --36247
contralateral approach.
4. Selective right anterior tibial angiography via contralateral
approach. -36248
5. Angioplasty of proximal, mid and distal superficial femoral artery. -37224
6. Angioplasty of mid to distal right popliteal artery. --
7. Angioplasty of proximal and mid right anterior tibial artery. 37228
8. Left femoral angiography via bolus chase method. -
.
DESCRIPTION OF PROCEDURE:
After obtaining informed consent, the patient was brought to the cardiac
catheterization laboratory. Both groins were prepared and draped in a
sterile manner. Gowns, masks, caps and drapes were used to maintain
strict sterile precautions. Intravenous Versed and fentanyl were used
to obtain moderate level of sedation. Lidocaine 1% was used for local
anesthesia. The left common femoral artery was localized using vascular
ultrasound and access to the left common femoral artery was obtained
with a micropuncture needle under ultrasound guidance. A standard 5
French sheath was introduced into the left femoral artery using modified
Seldinger technique. A pigtail catheter was then advanced over a wire
and placed in the abdominal aorta. Digital subtraction angiography of
the aortoiliac arteries was then done. The pigtail catheter was then
exchanged over a wire for a Contra II catheter. Crossover was then done
with this catheter using an Advantage Glidewire. Digital subtraction
angiography of the femoral artery, popliteal artery and right leg
vessels was then done sequentially.
After reviewing the images, the decision was taken to intervene on the
long segment of occlusion along the right SFA and mid to distal right
popliteal artery and possibly the anterior tibial arteries. An
Advantage Glidewire was introduced back and placed in the distal
popliteal artery. The Contra II catheter was removed and then the 5
French femoral sheath was exchanged for a 40 cm 6 French Destination
sheath, which was placed in the distal right common femoral artery. A
100 centimeter straight Glide catheter was now advanced over the wire
with the hopes of advancing it into the distal popliteal artery and
changing to an 0.018 system. However, the 0.018 wire could not
negotiate into the SFA, probably due to significant stenosis along the
path. Hence the 0.018 wire was removed and was removed and Super Stiff
Amplatz wire was introduced into the right popliteal artery and through
the Glide catheter. The straight Glide catheter was now removed.
Angioplasty of the proximal to distal SFA was then done using a 5.0 x
220 mm balloon with multiple inflations from 10 to 12 atmospheres. A
4.0 x 20 mm was then used to perform angioplasty of the mid to distal
popliteal artery. Of note, heparin was used for anticoagulation prior
to initiation of intervention and sequential samples were obtained to
maintain the ACT about 250 during the procedure.
At this point, we are working with an Advantage Glidewire. During the
angioplasty process, note was made that the Glidewire had gone into the
right anterior tibial artery. The Glidewire was advanced into the mid
anterior tibial artery. The balloon was now removed and a straight
Glide catheter once again advanced into the SFA. Selective angiography
of right SFA was then done showing good results with residual stenosis
of 10-20% along the vessel. Attempts to advance the straight Glide
catheter into the anterior tibial artery were unsuccessful. The
anterior Glidewire was now removed and a PT Graphix wire was advanced
through the Glide catheter into the anterior tibial artery. Multiple
times a 20 mm balloon was now advanced over this wire into the anterior
tibial artery. Angioplasty of proximal to mid anterior tibial artery
was done with multiple inflations from 8 to 12 atmospheres. The balloon
was then advanced into the proximal anterior tibial and selective
injection of anterior tibial was done showing intraluminal course and
location of the balloon. A Pilot 200 wire was now advanced through the
balloon back into the mid anterior tibial artery. The balloon was
exchanged for a 2.0 x 120 mm balloon. Multiple inflations of the
balloon were done in the proximal to mid anterior tibial artery from 6
to 12 atmospheres. Attempts to advance the Pilot wire into the distal
anterior tibial were unsuccessful. Final angiographic images were then
acquired after removing the balloon, showing no residual stenosis in the
proximal or mid anterior tibial. There was 1 vessel flow established to
the distal foot with collaterals from proximal and mid anterior tibial
supplying reconstituted common peroneal artery. The wires and balloons
were removed.
The Destination sheath was then exchanged with a regular wire for a 7
French standard sheath. A right femoral angiography with distal runoff
was then done using bolus chase method. The femoral sheath was then
secured in position and the patient was transferred to the recovery unit
for subsequent sheath removal. Vitals were stable at the end of the
procedure.
Estimated blood loss was 20 mL.
Fluoroscopy time was 28.8 minutes.
Fluoroscopy dose was 213214 mGy cm2.
Total contrast volume was 136 mL of Isovue.
ANGIOGRAPHIC FINDINGS:
Abdominal aorta shows moderate calcification. There is no stenosis
noted. There is tapering of the distal aorta. The ends were branching
into the iliac arteries.
There was calcification of the common iliac and external and internal
iliacs bilaterally. No stenosis was noted in the common or external
iliacs bilaterally. The internal iliacs were occluded in the mid to
distal segment bilaterally.
Right femoral angiography shows normal right common femoral artery,
which ends by branching into SFA and profunda femoral arteries. The
right SFA showed varying stenosis from 50 degrees in the proximal
segment involving the ostium with multiple tandem lesions varying from
70-90% from mid to distal segments of the vessel. The right profunda
femoris artery shows a 90% stenosis proximally and it is occluded in the
mid segment.
The distal right popliteal artery shows a 99% stenosis. It ends by
giving rise to the anterior tibial and the tibioperoneal trunk. There
is subtotal occlusion of the ostium of the anterior tibial with a total
occlusion of the proximal anterior tibial artery.
The tibioperoneal trunk shows chronic total occlusion distally. The
common peroneal is seen reconstituting in the mid segments via
collaterals. Distal supply to the leg is from the reconstituted common
peroneal, which supplies the lateral aspect of the left foot via
collaterals.
Post-intervention, there was residual 20-30% stenosis in the mid and the
proximal right SFA and there was no stenosis in the right popliteal.
The right anterior tibial showed no residual stenosis in the proximal
and mid segment. It was completely occluded in the distal third.
Supply to the distal leg was again noted from the reconstituted common
peroneal artery, which was getting collaterals from the anterior tibial.
Left femoral angiography shows flush occlusion of the left superficial
femoral artery. The left profunda femoral arterygives supply to the leg
and via collaterals supplied left popliteal artery. Distal segments of
the left SFA are noted via retrograde flow from the reconstituted
popliteal artery. Distal supply to the left leg is again via 1 vessel,
which is from the peroneal. The peroneal itself shows 90% stenosis
proximally.
CONCLUSION:
1. Severe peripheral vascular disease with critical limb ischemia of
both feet.
2. Status post successful angioplasty of the right superficial femoral
artery, distal right popliteal artery, proximal and mid right anterior
tibial artery.
Thank You
Ruby
PROCEDURES PERFORMED:
1. Digital subtraction angiography of the abdominal and aortoiliac
vessels. ?75625, 75710
2. Selective iliofemoral angiography via contralateral approach.
3. Selective right superficial femoral artery angiography via --36247
contralateral approach.
4. Selective right anterior tibial angiography via contralateral
approach. -36248
5. Angioplasty of proximal, mid and distal superficial femoral artery. -37224
6. Angioplasty of mid to distal right popliteal artery. --
7. Angioplasty of proximal and mid right anterior tibial artery. 37228
8. Left femoral angiography via bolus chase method. -
.
DESCRIPTION OF PROCEDURE:
After obtaining informed consent, the patient was brought to the cardiac
catheterization laboratory. Both groins were prepared and draped in a
sterile manner. Gowns, masks, caps and drapes were used to maintain
strict sterile precautions. Intravenous Versed and fentanyl were used
to obtain moderate level of sedation. Lidocaine 1% was used for local
anesthesia. The left common femoral artery was localized using vascular
ultrasound and access to the left common femoral artery was obtained
with a micropuncture needle under ultrasound guidance. A standard 5
French sheath was introduced into the left femoral artery using modified
Seldinger technique. A pigtail catheter was then advanced over a wire
and placed in the abdominal aorta. Digital subtraction angiography of
the aortoiliac arteries was then done. The pigtail catheter was then
exchanged over a wire for a Contra II catheter. Crossover was then done
with this catheter using an Advantage Glidewire. Digital subtraction
angiography of the femoral artery, popliteal artery and right leg
vessels was then done sequentially.
After reviewing the images, the decision was taken to intervene on the
long segment of occlusion along the right SFA and mid to distal right
popliteal artery and possibly the anterior tibial arteries. An
Advantage Glidewire was introduced back and placed in the distal
popliteal artery. The Contra II catheter was removed and then the 5
French femoral sheath was exchanged for a 40 cm 6 French Destination
sheath, which was placed in the distal right common femoral artery. A
100 centimeter straight Glide catheter was now advanced over the wire
with the hopes of advancing it into the distal popliteal artery and
changing to an 0.018 system. However, the 0.018 wire could not
negotiate into the SFA, probably due to significant stenosis along the
path. Hence the 0.018 wire was removed and was removed and Super Stiff
Amplatz wire was introduced into the right popliteal artery and through
the Glide catheter. The straight Glide catheter was now removed.
Angioplasty of the proximal to distal SFA was then done using a 5.0 x
220 mm balloon with multiple inflations from 10 to 12 atmospheres. A
4.0 x 20 mm was then used to perform angioplasty of the mid to distal
popliteal artery. Of note, heparin was used for anticoagulation prior
to initiation of intervention and sequential samples were obtained to
maintain the ACT about 250 during the procedure.
At this point, we are working with an Advantage Glidewire. During the
angioplasty process, note was made that the Glidewire had gone into the
right anterior tibial artery. The Glidewire was advanced into the mid
anterior tibial artery. The balloon was now removed and a straight
Glide catheter once again advanced into the SFA. Selective angiography
of right SFA was then done showing good results with residual stenosis
of 10-20% along the vessel. Attempts to advance the straight Glide
catheter into the anterior tibial artery were unsuccessful. The
anterior Glidewire was now removed and a PT Graphix wire was advanced
through the Glide catheter into the anterior tibial artery. Multiple
times a 20 mm balloon was now advanced over this wire into the anterior
tibial artery. Angioplasty of proximal to mid anterior tibial artery
was done with multiple inflations from 8 to 12 atmospheres. The balloon
was then advanced into the proximal anterior tibial and selective
injection of anterior tibial was done showing intraluminal course and
location of the balloon. A Pilot 200 wire was now advanced through the
balloon back into the mid anterior tibial artery. The balloon was
exchanged for a 2.0 x 120 mm balloon. Multiple inflations of the
balloon were done in the proximal to mid anterior tibial artery from 6
to 12 atmospheres. Attempts to advance the Pilot wire into the distal
anterior tibial were unsuccessful. Final angiographic images were then
acquired after removing the balloon, showing no residual stenosis in the
proximal or mid anterior tibial. There was 1 vessel flow established to
the distal foot with collaterals from proximal and mid anterior tibial
supplying reconstituted common peroneal artery. The wires and balloons
were removed.
The Destination sheath was then exchanged with a regular wire for a 7
French standard sheath. A right femoral angiography with distal runoff
was then done using bolus chase method. The femoral sheath was then
secured in position and the patient was transferred to the recovery unit
for subsequent sheath removal. Vitals were stable at the end of the
procedure.
Estimated blood loss was 20 mL.
Fluoroscopy time was 28.8 minutes.
Fluoroscopy dose was 213214 mGy cm2.
Total contrast volume was 136 mL of Isovue.
ANGIOGRAPHIC FINDINGS:
Abdominal aorta shows moderate calcification. There is no stenosis
noted. There is tapering of the distal aorta. The ends were branching
into the iliac arteries.
There was calcification of the common iliac and external and internal
iliacs bilaterally. No stenosis was noted in the common or external
iliacs bilaterally. The internal iliacs were occluded in the mid to
distal segment bilaterally.
Right femoral angiography shows normal right common femoral artery,
which ends by branching into SFA and profunda femoral arteries. The
right SFA showed varying stenosis from 50 degrees in the proximal
segment involving the ostium with multiple tandem lesions varying from
70-90% from mid to distal segments of the vessel. The right profunda
femoris artery shows a 90% stenosis proximally and it is occluded in the
mid segment.
The distal right popliteal artery shows a 99% stenosis. It ends by
giving rise to the anterior tibial and the tibioperoneal trunk. There
is subtotal occlusion of the ostium of the anterior tibial with a total
occlusion of the proximal anterior tibial artery.
The tibioperoneal trunk shows chronic total occlusion distally. The
common peroneal is seen reconstituting in the mid segments via
collaterals. Distal supply to the leg is from the reconstituted common
peroneal, which supplies the lateral aspect of the left foot via
collaterals.
Post-intervention, there was residual 20-30% stenosis in the mid and the
proximal right SFA and there was no stenosis in the right popliteal.
The right anterior tibial showed no residual stenosis in the proximal
and mid segment. It was completely occluded in the distal third.
Supply to the distal leg was again noted from the reconstituted common
peroneal artery, which was getting collaterals from the anterior tibial.
Left femoral angiography shows flush occlusion of the left superficial
femoral artery. The left profunda femoral arterygives supply to the leg
and via collaterals supplied left popliteal artery. Distal segments of
the left SFA are noted via retrograde flow from the reconstituted
popliteal artery. Distal supply to the left leg is again via 1 vessel,
which is from the peroneal. The peroneal itself shows 90% stenosis
proximally.
CONCLUSION:
1. Severe peripheral vascular disease with critical limb ischemia of
both feet.
2. Status post successful angioplasty of the right superficial femoral
artery, distal right popliteal artery, proximal and mid right anterior
tibial artery.
Thank You
Ruby
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