AgnieszkaLakritz
Networker
I think 37221,37224,75716 my question is if we code cath placement for angiography in this case. I know it's bundled with few exceptions, it was Lt femoral access with bilateral angio and intervention at contralateral side. That's why i am questioning if 36246 should be added.
Thank you in advance for all your answers.
PREOPERATIVE DIAGNOSIS:
Severe bilateral lifestyle limiting intermittent claudication
POSTOPERATIVE DIAGNOSIS:
Severe bilateral lifestyle limiting intermittent claudication
Severe right external iliac stenosis
Severe in-stent restenosis of bilateral SFA
PROCEDURE:
Pelvic angiography
Bilateral selective lower extremity angiography
Stenting of right external iliac artery with self-expanding bare-metal stent
PTA of right common femoral artery and right superficial femoral artery with drug-coated balloons
FINDINGS:
Pelvic angiography:
Small abdominal aortic aneurysm right above the aortic bifurcation.
Right common iliac artery is patent with moderate 30 to 40% stenosis, right external iliac artery with severe 70% stenosis at proximal segment, right internal iliac arteries patent.
Left common iliac artery is patent with mild diffuse disease, left external iliac artery with moderate diffuse disease, left internal iliac artery is patent.
Right lower extremity angiography:
Right common femoral artery with moderate 50 to 60% stenosis at distal segment, right SFA with long stented segment from the ostium to distal segment with severe 80% in-stent restenosis at its proximal half, right profunda is large and patent, right above-knee popliteal artery is heavily calcified moderate 50 to 60% stenosis, right below-knee popliteal artery is widely patent, the trifurcation is widely patent with three-vessel runoff to the foot.
Left lower extremity angiography: Left common femoral artery with moderate 50 to 60% stenosis at proximal portion, left SFA has a stent at its mid and distal portions. There is critical subtotal occlusion at the proximal SFA, moderate diffuse in-stent restenosis, the left profunda is large and patent, above-knee popliteal artery with moderate diffuse 50% stenosis, below-knee vessels are faintly opacified but seems to be patent with three-vessel runoff to the foot.
Intervention: Significant 30 to 40 mmHg pressure gradient was measured across the right external iliac artery. Stenting of the right external iliac artery with an ever flex 8.0/60 mm self-expanding stent, postdilated with a 7.0/60 mm balloon. Excellent final angiographic result with no residual pressure gradient.
Balloon angioplasty of the right common femoral artery and proximal right SFA in-stent with a Lutonix 6.0/150 mm drug-coated balloon. Residual stenosis at the ostium of the SFA was further dilated with Dorado 6.0/40 mm NC balloon high-pressure. Balloon angioplasty of the above-knee popliteal artery with a Lutonix 5.0/150 mm drug-coated balloon. Satisfactory final angiographic result across the right SFA and above-knee popliteal arteries.
Conclusions:
1. Severe bilateral lifestyle limiting lower extremity claudication. Recent ABI/PVR shows recurrent severe PAD with ABI around 0.5 at both legs. Patient had bilateral prior endovascular interventions with his stenting of both SFAs.
2. Severe right inflow disease of the right external iliac artery and severe right SFA in-stent restenosis.
3. At least moderate left inflow disease of the left external iliac artery and severe left SFA restenosis.
4. Successful stenting of right external iliac artery with self-expanding stent.
5. Successful reintervention of right common femoral artery and right SFA with drug-coated balloon. PTA of right above-knee popliteal artery with a drug-coated balloon.
Recommendations:
1. Optimal risk factor modification including tight glycemic control and improved lipid lowering.
2. Return for intervention on left external iliac artery and left SFA in 4 weeks.
DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was brought to the cardiac catheterization lab, prepped and draped in usual sterile manner for femoral access procedure. The patient was sedated with Versed and fentanyl. 2% lidocaine applied to left groin area (initial plan was to intervene on the left leg, but we had difficulty in gaining the right femoral access).
Arterial access was gained in the left groin under fluroscopic guidance, using micropuncture technique, and 5F sheath was inserted in the LCFA. Selective segmental left lower extremity angiography was performed via the sheath. A 4F UF catheter was advanced to the distal abdominal aorta and pelvic angiography performed. Then, the catheter was advanced across the aortic bifurcation, up and over, over an angled Glidewire, with the tip of the catheter positioned in the right external iliac artery. Segmental selective right lower extremity angiography was performed
We then proceeded with right SFA intervention. The short sheath was exchanged for a 65 cm Terumo Destination sheath over a stiff Amplatz wire. Bolus heparin was given and repeated to achive an ACT around 250.
We then advanced a 0.035 angled Glidewire supported by angled 4F Glidecatheter across the SFA into the below the knee popliteal artery. The Glidewire was exchanged for a Super stiff long Amplatz wire. The proximal SFA and right common femoral artery were dilated with the loop tonics 6.0/150 mm balloon. The above-knee popliteal artery was dilated with a loop tonics 5.0/150 mm balloon. Additional angioplasty of the ostium of the right SFA was performed with an Dorado 6.0/40 mm noncompliant balloon to high pressure. The origin of the right profunda was then dilated with the 4.0/60 mm Coyote balloon to preserve patency of the profunda. We then withdrew the sheath to the proximal right common iliac artery. A 5F glide catheter was advanced to the right SFA. We recorded simultaneous pressures while the glide catheter was slowly pulled back from the SFA into the right common iliac artery. We noticed most of the pressure gradient was across the lesion in the right external iliac artery. This lesion was treated with a Ever Flex 8.0/60 mm self-expanding stent. The stent was postdilated with a 7.0/60 mm Mustang balloon.
Completion angiography showed very good angiographic result, with no residual significant stenosis or dissection, and preserved runoff to the foot.
The long sheath in the left groin was exchanged for a short 6F sheath, which was sutured in place, to be later manually removed.
Patient tolerated the procedure well, no complications were noted. He was transferred to the holding area in stable condition.
I noticed a robust +2 DP pulse in the right foot after the procedure
Thank you in advance for all your answers.
PREOPERATIVE DIAGNOSIS:
Severe bilateral lifestyle limiting intermittent claudication
POSTOPERATIVE DIAGNOSIS:
Severe bilateral lifestyle limiting intermittent claudication
Severe right external iliac stenosis
Severe in-stent restenosis of bilateral SFA
PROCEDURE:
Pelvic angiography
Bilateral selective lower extremity angiography
Stenting of right external iliac artery with self-expanding bare-metal stent
PTA of right common femoral artery and right superficial femoral artery with drug-coated balloons
FINDINGS:
Pelvic angiography:
Small abdominal aortic aneurysm right above the aortic bifurcation.
Right common iliac artery is patent with moderate 30 to 40% stenosis, right external iliac artery with severe 70% stenosis at proximal segment, right internal iliac arteries patent.
Left common iliac artery is patent with mild diffuse disease, left external iliac artery with moderate diffuse disease, left internal iliac artery is patent.
Right lower extremity angiography:
Right common femoral artery with moderate 50 to 60% stenosis at distal segment, right SFA with long stented segment from the ostium to distal segment with severe 80% in-stent restenosis at its proximal half, right profunda is large and patent, right above-knee popliteal artery is heavily calcified moderate 50 to 60% stenosis, right below-knee popliteal artery is widely patent, the trifurcation is widely patent with three-vessel runoff to the foot.
Left lower extremity angiography: Left common femoral artery with moderate 50 to 60% stenosis at proximal portion, left SFA has a stent at its mid and distal portions. There is critical subtotal occlusion at the proximal SFA, moderate diffuse in-stent restenosis, the left profunda is large and patent, above-knee popliteal artery with moderate diffuse 50% stenosis, below-knee vessels are faintly opacified but seems to be patent with three-vessel runoff to the foot.
Intervention: Significant 30 to 40 mmHg pressure gradient was measured across the right external iliac artery. Stenting of the right external iliac artery with an ever flex 8.0/60 mm self-expanding stent, postdilated with a 7.0/60 mm balloon. Excellent final angiographic result with no residual pressure gradient.
Balloon angioplasty of the right common femoral artery and proximal right SFA in-stent with a Lutonix 6.0/150 mm drug-coated balloon. Residual stenosis at the ostium of the SFA was further dilated with Dorado 6.0/40 mm NC balloon high-pressure. Balloon angioplasty of the above-knee popliteal artery with a Lutonix 5.0/150 mm drug-coated balloon. Satisfactory final angiographic result across the right SFA and above-knee popliteal arteries.
Conclusions:
1. Severe bilateral lifestyle limiting lower extremity claudication. Recent ABI/PVR shows recurrent severe PAD with ABI around 0.5 at both legs. Patient had bilateral prior endovascular interventions with his stenting of both SFAs.
2. Severe right inflow disease of the right external iliac artery and severe right SFA in-stent restenosis.
3. At least moderate left inflow disease of the left external iliac artery and severe left SFA restenosis.
4. Successful stenting of right external iliac artery with self-expanding stent.
5. Successful reintervention of right common femoral artery and right SFA with drug-coated balloon. PTA of right above-knee popliteal artery with a drug-coated balloon.
Recommendations:
1. Optimal risk factor modification including tight glycemic control and improved lipid lowering.
2. Return for intervention on left external iliac artery and left SFA in 4 weeks.
DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was brought to the cardiac catheterization lab, prepped and draped in usual sterile manner for femoral access procedure. The patient was sedated with Versed and fentanyl. 2% lidocaine applied to left groin area (initial plan was to intervene on the left leg, but we had difficulty in gaining the right femoral access).
Arterial access was gained in the left groin under fluroscopic guidance, using micropuncture technique, and 5F sheath was inserted in the LCFA. Selective segmental left lower extremity angiography was performed via the sheath. A 4F UF catheter was advanced to the distal abdominal aorta and pelvic angiography performed. Then, the catheter was advanced across the aortic bifurcation, up and over, over an angled Glidewire, with the tip of the catheter positioned in the right external iliac artery. Segmental selective right lower extremity angiography was performed
We then proceeded with right SFA intervention. The short sheath was exchanged for a 65 cm Terumo Destination sheath over a stiff Amplatz wire. Bolus heparin was given and repeated to achive an ACT around 250.
We then advanced a 0.035 angled Glidewire supported by angled 4F Glidecatheter across the SFA into the below the knee popliteal artery. The Glidewire was exchanged for a Super stiff long Amplatz wire. The proximal SFA and right common femoral artery were dilated with the loop tonics 6.0/150 mm balloon. The above-knee popliteal artery was dilated with a loop tonics 5.0/150 mm balloon. Additional angioplasty of the ostium of the right SFA was performed with an Dorado 6.0/40 mm noncompliant balloon to high pressure. The origin of the right profunda was then dilated with the 4.0/60 mm Coyote balloon to preserve patency of the profunda. We then withdrew the sheath to the proximal right common iliac artery. A 5F glide catheter was advanced to the right SFA. We recorded simultaneous pressures while the glide catheter was slowly pulled back from the SFA into the right common iliac artery. We noticed most of the pressure gradient was across the lesion in the right external iliac artery. This lesion was treated with a Ever Flex 8.0/60 mm self-expanding stent. The stent was postdilated with a 7.0/60 mm Mustang balloon.
Completion angiography showed very good angiographic result, with no residual significant stenosis or dissection, and preserved runoff to the foot.
The long sheath in the left groin was exchanged for a short 6F sheath, which was sutured in place, to be later manually removed.
Patient tolerated the procedure well, no complications were noted. He was transferred to the holding area in stable condition.
I noticed a robust +2 DP pulse in the right foot after the procedure