rparikh
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Need help with codes: this is what I have 75625,36247,75710,37184,37185,37211,37228,and 37232
PROCEDURES PERFORMED:
1. Abdominal aortography. -75625
2. Selective right common and external iliac artery angiography with -36246
the right lower extremity runoff angiogram. -75710
3. Selective angiography of the right superficial femoral artery with --36247
right lower extremity runoff angiogram.
4. Selective angiography of the right popliteal artery with right lower -36247
extremity runoff angiogram.
5. Selective angiography of the right tibioperoneal trunk.
6. Selective angiography of the right posterior tibial artery. ---36247
7. Selective angiography of right anterior tibial artery. ------36247
8. AngioJet thrombectomy of the right posterior tibial artery. ---37184
9. AngioJet thrombectomy of the right anterior tibial artery. ---37185
10. Injection of intraarterial thrombolytic (TPA) into right popliteal -37211
artery and the right tibioperoneal trunk.
11. PTA of the right posterior tibial artery. -37228
12. PTA of the right anterior tibial artery. -37232
OPERATIVE FINDINGS:
ABDOMINAL AORTOGRAPHY:
The abdominal aortogram demonstrates modest caliber infrarenal abdominal
aortic aneurysm. There is significant tortuosity of the iliac arteries
on both sides, especially the left iliofemoral system. There is
significant fluoroscopic calcification of the distal abdominal aorta and
the iliofemoral vessels on both sides. Although tortuous, the
iliofemoral vessels on both sides are patent.
Selective angiography of the right common and external iliac arteries
(cannulation from the contralateral side): The right side LVAO femoral
vessels are widely patent. The vessels are tortuous. The right lower
extremity runoff angiogram demonstrates patency of the right superficial
femoral and the right profunda femoris arteries.
Selective angiography of the right superficial femoral artery
(cannulation from the contralateral side): The right superficial
femoral artery is widely patent. There is significant fluoroscopic
calcification along with fusiform aneurysmal dilatation of the popliteal
artery. There appears to be organized thrombus within the walls of the
aneurysm of the popliteal artery. This seems to be pretty large
aneurysm of the right popliteal artery. The right anterior tibial
artery is 100% proximally occluded with what appears to be a thrombus.
The right tibioperoneal trunk is patent. The tibioperoneal trunk
bifurcates in the right posterior tibial and the right peroneal
arteries. The right peroneal and posterior tibial arteries are 100%
occluded. There is significant fluoroscopic calcification of the right
anterior and posterior tibial arteries.
INTERVENTION:
Angiojet thrombectomy followed by PTA of the right posterior tibial
artery (2.5 x 200 mm OTW balloon passed over a 0.014 inch guidewire):
One hundred percent occlusion reduced 50-60% stenosis in the mid segment
of the vessel with sluggish flow in the distal vessel.
AngioJet thrombectomy with PTA of the right anterior tibial artery: The
vessel was initially occluded in its proximal segment. We managed to
establish flow into the mid to distal segment of the vessel. The distal
portion of the right ATA going in the ankle and the foot continued to be
occluded.
INDICATIONS AND BRIEF HISTORY:
The patient is ____old who came with a cold right
foot. He had a pulseless, cold and mottled right leg and foot. He has
been having pain for the last 7 days. He has multiple other medical
problems including immobility, left hip fracture, bilateral hip
replacement surgeries in the past, known coronary disease with previous
bypass surgery and severe aortic valvular stenosis. The patient was
seen by me. He was having a lot of pain in his right leg. There were
no pulses either felt or Dopplered in the right foot/leg. I spoke to
the patient and his son Kevin. I recommended peripheral angiography
with possible thrombectomy, PTA or stenting. All the risks were
discussed. A written informed consent has been obtained. The patient's
DNI/DNR status was rescinded for 48-72 hours. This was discussed with
the patient and with the son, Kevin.
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
right groin for local anesthesia. Under fluoroscopy, we realized that
the left groin anatomy was significantly distorted. He had bilateral
hip prostheses. The left hip prosthesis was out of the socket.
Arterial axis was obtained in the standard micropuncture needle. A
short 6 French sheath was placed in the left common femoral artery over
a J tipped 0.035 inch standard guidewire. There was significant
tortuosity of the right iliofemoral vessel evident on fluoroscopy. A
260 cm long 0.035 inch Glidewire was passed into the abdominal aorta.
We then passed a short pigtail catheter into the abdominal aorta. An
abdominal aortogram was performed by power injecting 30 mL of nonionic
contrast at a rate of 15 mL per second. There was moderate sized
aneurysm in the infrarenal portion of the abdominal aorta. The
iliofemoral vessels on both sides appeared widely patent although it is
very tortuous.
We cannulated the right common femoral artery from the left side
arterial access with 5 French Contra II catheter. The Glidewire was
then advanced over the Contra II catheter into the right superficial
femoral artery. The Contra II catheter was removed and a glide catheter
was passed into the right superficial femoral artery. Several
angiograms of the right iliofemoral arteries and the right superficial
femoral artery with right lower extremity runoff angiograms were
performed. The 6 French glide catheter was then carefully passed into
the right popliteal artery. Angiography and injection of contrast in
the right popliteal artery from the contralateral side demonstrated an
aneurysm of the right popliteal artery with complete occlusion of all
the 3 infrapopliteal vessels. There was no blood flow going down the
leg or the foot.
A 260 cm long Advantage Glidewire was passed into the right
tibioperoneal trunk. The glide catheter was then removed. We then
advanced a 70 cm long Destination sheath into the distal right
superficial femoral artery.
A 0.014 inch x 260 cm long PT Graphix wire was passed through a 135 cm
long Quick-Cross catheter into the right posterior tibial artery. The
tip of the wire was positioned in the distal right PTA at the region of
the ankle. We then performed AngioJet thrombectomy of the distal, mid
and proximal segment of the right posterior tibial artery. Subsequent
angiograms revealed a trickle of flow down the distal vessel. We then
performed balloon angioplasty of the arteries several times with a 2.5
x 200 mm long over the wire balloon. After several balloon dilatations,
sluggish flow of contrast was restored in the right PTA. There appeared
to be a lot of sludge and thrombus within the vessel, especially in the
mid to distal segments. The distal PTA remained occluded beyond the
ankle.
We then passed a new PT Graphix wire through SuperCross catheter into
the right anterior tibial artery. The tip of the wire was positioned in
the distal vessel again. We then performed AngioJet thrombectomy of the
right ATA followed by PTA with a new 2.5 x 120 mm OTW balloon. Several
balloon inflations were performed in the distal, mid and proximal
segments of the right ATA. The distal segment of the vessel remained
occluded, but there was patency of the vessel up to the mid segment.
Next, we introduced an angled tipped Glidewire into the right
tibioperoneal trunk. We then hand injected 35-40 mL of thrombolytic
solution containing TPA. The total dose injected was nearly 8 mg.
Subsequent angiograms performed through the glide catheter revealed
improved flow in the right posterior tibial artery all the way to the
ankle. There was, however, no flow into the right foot through any of
these vessels. The overall result showed an improved flow into the
right leg following the intervention, but the right foot continued to
remain ischemic since there was no flow down any of the vessels.
The long left femoral arterial sheath was removed and we introduced an 8
French 21 cm long sheath to provide adequate hemostasis. This bigger
caliber sheath was introduced into the left femoral artery since there
was bleeding around the sheath insertion site. This certainly gave
better control to the bleeding. There was a modest sized hematoma,
which remained stable. A brief left iliofemoral angiogram was performed
through the sheath and there was no evidence of any complications
including active bleeding.
The patient received a total of around 120 mL of nonionic contrast. No
complications. For the intervention, the patient received a total of
7000 units of unfractionated heparin. The final ACT was 220 seconds.
the right leg up to the foot was warm. The right foot, especially the
toes continued to remain mottled and cool. The right posterior tibial
pulse was actually palpable at the completion of the procedure. The
vessels were Dopplered and we got a fairly good Doppler signal from the
right posterior tibial artery.
RECOMMENDATIONS:
Continue the patient on aspirin 81 mg daily, Plavix 75 mg daily and
start the patient on intravenous heparin infusion. We will continue to
monitor the patient's situation in the telemetry unit. He will require
IV antibiotics for his urinary tract infection, which will be ordered by
the hospitalist, urinalysis and urine cultures are necessary. The
patient received 2 units of packed red cells during the procedure for a
preprocedure hemoglobin of 7.5.
Thank You
PROCEDURES PERFORMED:
1. Abdominal aortography. -75625
2. Selective right common and external iliac artery angiography with -36246
the right lower extremity runoff angiogram. -75710
3. Selective angiography of the right superficial femoral artery with --36247
right lower extremity runoff angiogram.
4. Selective angiography of the right popliteal artery with right lower -36247
extremity runoff angiogram.
5. Selective angiography of the right tibioperoneal trunk.
6. Selective angiography of the right posterior tibial artery. ---36247
7. Selective angiography of right anterior tibial artery. ------36247
8. AngioJet thrombectomy of the right posterior tibial artery. ---37184
9. AngioJet thrombectomy of the right anterior tibial artery. ---37185
10. Injection of intraarterial thrombolytic (TPA) into right popliteal -37211
artery and the right tibioperoneal trunk.
11. PTA of the right posterior tibial artery. -37228
12. PTA of the right anterior tibial artery. -37232
OPERATIVE FINDINGS:
ABDOMINAL AORTOGRAPHY:
The abdominal aortogram demonstrates modest caliber infrarenal abdominal
aortic aneurysm. There is significant tortuosity of the iliac arteries
on both sides, especially the left iliofemoral system. There is
significant fluoroscopic calcification of the distal abdominal aorta and
the iliofemoral vessels on both sides. Although tortuous, the
iliofemoral vessels on both sides are patent.
Selective angiography of the right common and external iliac arteries
(cannulation from the contralateral side): The right side LVAO femoral
vessels are widely patent. The vessels are tortuous. The right lower
extremity runoff angiogram demonstrates patency of the right superficial
femoral and the right profunda femoris arteries.
Selective angiography of the right superficial femoral artery
(cannulation from the contralateral side): The right superficial
femoral artery is widely patent. There is significant fluoroscopic
calcification along with fusiform aneurysmal dilatation of the popliteal
artery. There appears to be organized thrombus within the walls of the
aneurysm of the popliteal artery. This seems to be pretty large
aneurysm of the right popliteal artery. The right anterior tibial
artery is 100% proximally occluded with what appears to be a thrombus.
The right tibioperoneal trunk is patent. The tibioperoneal trunk
bifurcates in the right posterior tibial and the right peroneal
arteries. The right peroneal and posterior tibial arteries are 100%
occluded. There is significant fluoroscopic calcification of the right
anterior and posterior tibial arteries.
INTERVENTION:
Angiojet thrombectomy followed by PTA of the right posterior tibial
artery (2.5 x 200 mm OTW balloon passed over a 0.014 inch guidewire):
One hundred percent occlusion reduced 50-60% stenosis in the mid segment
of the vessel with sluggish flow in the distal vessel.
AngioJet thrombectomy with PTA of the right anterior tibial artery: The
vessel was initially occluded in its proximal segment. We managed to
establish flow into the mid to distal segment of the vessel. The distal
portion of the right ATA going in the ankle and the foot continued to be
occluded.
INDICATIONS AND BRIEF HISTORY:
The patient is ____old who came with a cold right
foot. He had a pulseless, cold and mottled right leg and foot. He has
been having pain for the last 7 days. He has multiple other medical
problems including immobility, left hip fracture, bilateral hip
replacement surgeries in the past, known coronary disease with previous
bypass surgery and severe aortic valvular stenosis. The patient was
seen by me. He was having a lot of pain in his right leg. There were
no pulses either felt or Dopplered in the right foot/leg. I spoke to
the patient and his son Kevin. I recommended peripheral angiography
with possible thrombectomy, PTA or stenting. All the risks were
discussed. A written informed consent has been obtained. The patient's
DNI/DNR status was rescinded for 48-72 hours. This was discussed with
the patient and with the son, Kevin.
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
right groin for local anesthesia. Under fluoroscopy, we realized that
the left groin anatomy was significantly distorted. He had bilateral
hip prostheses. The left hip prosthesis was out of the socket.
Arterial axis was obtained in the standard micropuncture needle. A
short 6 French sheath was placed in the left common femoral artery over
a J tipped 0.035 inch standard guidewire. There was significant
tortuosity of the right iliofemoral vessel evident on fluoroscopy. A
260 cm long 0.035 inch Glidewire was passed into the abdominal aorta.
We then passed a short pigtail catheter into the abdominal aorta. An
abdominal aortogram was performed by power injecting 30 mL of nonionic
contrast at a rate of 15 mL per second. There was moderate sized
aneurysm in the infrarenal portion of the abdominal aorta. The
iliofemoral vessels on both sides appeared widely patent although it is
very tortuous.
We cannulated the right common femoral artery from the left side
arterial access with 5 French Contra II catheter. The Glidewire was
then advanced over the Contra II catheter into the right superficial
femoral artery. The Contra II catheter was removed and a glide catheter
was passed into the right superficial femoral artery. Several
angiograms of the right iliofemoral arteries and the right superficial
femoral artery with right lower extremity runoff angiograms were
performed. The 6 French glide catheter was then carefully passed into
the right popliteal artery. Angiography and injection of contrast in
the right popliteal artery from the contralateral side demonstrated an
aneurysm of the right popliteal artery with complete occlusion of all
the 3 infrapopliteal vessels. There was no blood flow going down the
leg or the foot.
A 260 cm long Advantage Glidewire was passed into the right
tibioperoneal trunk. The glide catheter was then removed. We then
advanced a 70 cm long Destination sheath into the distal right
superficial femoral artery.
A 0.014 inch x 260 cm long PT Graphix wire was passed through a 135 cm
long Quick-Cross catheter into the right posterior tibial artery. The
tip of the wire was positioned in the distal right PTA at the region of
the ankle. We then performed AngioJet thrombectomy of the distal, mid
and proximal segment of the right posterior tibial artery. Subsequent
angiograms revealed a trickle of flow down the distal vessel. We then
performed balloon angioplasty of the arteries several times with a 2.5
x 200 mm long over the wire balloon. After several balloon dilatations,
sluggish flow of contrast was restored in the right PTA. There appeared
to be a lot of sludge and thrombus within the vessel, especially in the
mid to distal segments. The distal PTA remained occluded beyond the
ankle.
We then passed a new PT Graphix wire through SuperCross catheter into
the right anterior tibial artery. The tip of the wire was positioned in
the distal vessel again. We then performed AngioJet thrombectomy of the
right ATA followed by PTA with a new 2.5 x 120 mm OTW balloon. Several
balloon inflations were performed in the distal, mid and proximal
segments of the right ATA. The distal segment of the vessel remained
occluded, but there was patency of the vessel up to the mid segment.
Next, we introduced an angled tipped Glidewire into the right
tibioperoneal trunk. We then hand injected 35-40 mL of thrombolytic
solution containing TPA. The total dose injected was nearly 8 mg.
Subsequent angiograms performed through the glide catheter revealed
improved flow in the right posterior tibial artery all the way to the
ankle. There was, however, no flow into the right foot through any of
these vessels. The overall result showed an improved flow into the
right leg following the intervention, but the right foot continued to
remain ischemic since there was no flow down any of the vessels.
The long left femoral arterial sheath was removed and we introduced an 8
French 21 cm long sheath to provide adequate hemostasis. This bigger
caliber sheath was introduced into the left femoral artery since there
was bleeding around the sheath insertion site. This certainly gave
better control to the bleeding. There was a modest sized hematoma,
which remained stable. A brief left iliofemoral angiogram was performed
through the sheath and there was no evidence of any complications
including active bleeding.
The patient received a total of around 120 mL of nonionic contrast. No
complications. For the intervention, the patient received a total of
7000 units of unfractionated heparin. The final ACT was 220 seconds.
the right leg up to the foot was warm. The right foot, especially the
toes continued to remain mottled and cool. The right posterior tibial
pulse was actually palpable at the completion of the procedure. The
vessels were Dopplered and we got a fairly good Doppler signal from the
right posterior tibial artery.
RECOMMENDATIONS:
Continue the patient on aspirin 81 mg daily, Plavix 75 mg daily and
start the patient on intravenous heparin infusion. We will continue to
monitor the patient's situation in the telemetry unit. He will require
IV antibiotics for his urinary tract infection, which will be ordered by
the hospitalist, urinalysis and urine cultures are necessary. The
patient received 2 units of packed red cells during the procedure for a
preprocedure hemoglobin of 7.5.
Thank You