suela923@aol.com
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I didn't code 37228 for the plasty of the tib-per trunk because I thought the trunk was not considered a separate vessel for intervention unless it was the only vessel treated or if it's treated in addition to the anterior tibial. Am I misunderstanding something here?
Procedure date: 7/30/14
Procedure: Bilateral selective lower extremity angiography; focused forced
angioplasty of left tibioperoneal trunk, popliteal, and proximal through
mid SFA
Access was obtained via the right common femoral artery utilizing a
modified Seldinger technique. A 5-French 11 cm sheath was inserted. The
left common iliac artery ostium was selectively engaged with a 5-French IM
catheter. Left lower extremity arterial angiography was then performed. No
prior angiography existed prior to the study. The findings of that are as
follows:
1. The left common iliac, internal iliac, and external iliac arteries all
have mild diffuse disease but are widely patent
2. Left common femoral is widely patent
3. The left profunda has mild to moderate diffuse disease throughout but
is patent
4. The left SFA demonstrates mild to moderate proximal disease that
becomes more significant at about the level of the lesser trochanter.
There is then severe diffuse disease through the start of the abductor
canal at which point there is once again mild to moderate disease. Several
of these areas of severe disease are up to 90% in severity.
5. There is severe diffuse disease of the distal popliteal through ostial
tibioperoneal trunk. Slow filling is noted throughout the distal SFA on
through this lesion.
6. The anterior tibial, peroneal, and posterior tibial are all severely
diffusely diseased. There is some antegrade filling of the anterior tibial
as well as the first half of the peroneal but initially there does not
appear to be any significant degree of antegrade filling of the posterior
tibial though collateral filling is seen further down that vessel. All the
tibials are heavily calcified and visible under fluoroscopy without
contrast.
Given the patient's severe symptoms and known high risk status for
vascular surgery which he has previously declined it was deemed
appropriate to proceed on with percutaneous intervention even though I did
not feel as though he was an acceptable candidate for stenting due to his
poor outflow. We therefore determined his best therapeutic option was
likely focused forced angioplasty to minimize barotrauma to the vessel and
hopefully reduce the likelihood of restenosis. A 5-French IM catheter was
used to advance a stiff angled zip wire into the proximal SFA over which
the sheath was exchanged for a 6-French Ansel 1 sheath. Therapeutic
anticoagulation was then achieved with heparinization. I then used a 0.014
Choice PT wire to navigate into the mid peroneal. We then performed
sequential dilation of the proximal tibioperoneal trunk through mid
popliteal utilizing a 2 mm x 40 mm chocolate balloon. This was performed
at low atmospheres. We then utilized a 4 mm x 1 20 mm chocolate balloon to
treat the entirety of the mid through proximal SFA. This was performed at
up to 8 atmospheres. All inflations were at least 3 minutes in duration.
Following these inflations repeat angiography demonstrated
mild-to-moderate recoil throughout the SFA and popliteal distributions but
very brisk antegrade filling now out-competing prior collateral dependent
filling with brisk runoff to the tibials. He did retain severe
infrapopliteal disease with his anterior tibial being his best runoff
vessel. Given the very brisk appearance of flow with no evidence of
dissection we decided to avoid further trauma to the vessel and did not
dilate further. The sheath was withdrawn to the abdominal aorta and the
wire redirected up that over which the sheath was exchanged for a 6-French
11 cm sheath. Sheath SideArm angiography was used to perform right lower
extremity runoff. This demonstrated the following:
1. Vascular access is in the proximal one-third of the common femoral
which is relatively disease free while the entirety of the common femoral
is widely patent
2. The right profunda is widely patent
3. The right SFA has moderate diffuse disease starting with the proximal
segment including several areas of stenosis of 60-70% while the tightest
lesions appear to be in the distal SFA at up to 90%
4. The right popliteal has a focal 90% stenosis in the mid vessel while
the remainder of that vessel is moderately diffusely diseased
5. All 3 tibial vessels are severely diffusely diseased with the
posterior tibial appearing the most patent while the anterior tibial does
continue to get flow halfway down the calf though may have several areas
of chronic total occlusion with bridging collaterals.
Based on sheath angiography it was deemed amenable to vascular closure.
Hemostasis was achieved with a 6-French Exoseal device plus adjunctive
manual compression.
Procedure date: 7/30/14
Procedure: Bilateral selective lower extremity angiography; focused forced
angioplasty of left tibioperoneal trunk, popliteal, and proximal through
mid SFA
Access was obtained via the right common femoral artery utilizing a
modified Seldinger technique. A 5-French 11 cm sheath was inserted. The
left common iliac artery ostium was selectively engaged with a 5-French IM
catheter. Left lower extremity arterial angiography was then performed. No
prior angiography existed prior to the study. The findings of that are as
follows:
1. The left common iliac, internal iliac, and external iliac arteries all
have mild diffuse disease but are widely patent
2. Left common femoral is widely patent
3. The left profunda has mild to moderate diffuse disease throughout but
is patent
4. The left SFA demonstrates mild to moderate proximal disease that
becomes more significant at about the level of the lesser trochanter.
There is then severe diffuse disease through the start of the abductor
canal at which point there is once again mild to moderate disease. Several
of these areas of severe disease are up to 90% in severity.
5. There is severe diffuse disease of the distal popliteal through ostial
tibioperoneal trunk. Slow filling is noted throughout the distal SFA on
through this lesion.
6. The anterior tibial, peroneal, and posterior tibial are all severely
diffusely diseased. There is some antegrade filling of the anterior tibial
as well as the first half of the peroneal but initially there does not
appear to be any significant degree of antegrade filling of the posterior
tibial though collateral filling is seen further down that vessel. All the
tibials are heavily calcified and visible under fluoroscopy without
contrast.
Given the patient's severe symptoms and known high risk status for
vascular surgery which he has previously declined it was deemed
appropriate to proceed on with percutaneous intervention even though I did
not feel as though he was an acceptable candidate for stenting due to his
poor outflow. We therefore determined his best therapeutic option was
likely focused forced angioplasty to minimize barotrauma to the vessel and
hopefully reduce the likelihood of restenosis. A 5-French IM catheter was
used to advance a stiff angled zip wire into the proximal SFA over which
the sheath was exchanged for a 6-French Ansel 1 sheath. Therapeutic
anticoagulation was then achieved with heparinization. I then used a 0.014
Choice PT wire to navigate into the mid peroneal. We then performed
sequential dilation of the proximal tibioperoneal trunk through mid
popliteal utilizing a 2 mm x 40 mm chocolate balloon. This was performed
at low atmospheres. We then utilized a 4 mm x 1 20 mm chocolate balloon to
treat the entirety of the mid through proximal SFA. This was performed at
up to 8 atmospheres. All inflations were at least 3 minutes in duration.
Following these inflations repeat angiography demonstrated
mild-to-moderate recoil throughout the SFA and popliteal distributions but
very brisk antegrade filling now out-competing prior collateral dependent
filling with brisk runoff to the tibials. He did retain severe
infrapopliteal disease with his anterior tibial being his best runoff
vessel. Given the very brisk appearance of flow with no evidence of
dissection we decided to avoid further trauma to the vessel and did not
dilate further. The sheath was withdrawn to the abdominal aorta and the
wire redirected up that over which the sheath was exchanged for a 6-French
11 cm sheath. Sheath SideArm angiography was used to perform right lower
extremity runoff. This demonstrated the following:
1. Vascular access is in the proximal one-third of the common femoral
which is relatively disease free while the entirety of the common femoral
is widely patent
2. The right profunda is widely patent
3. The right SFA has moderate diffuse disease starting with the proximal
segment including several areas of stenosis of 60-70% while the tightest
lesions appear to be in the distal SFA at up to 90%
4. The right popliteal has a focal 90% stenosis in the mid vessel while
the remainder of that vessel is moderately diffusely diseased
5. All 3 tibial vessels are severely diffusely diseased with the
posterior tibial appearing the most patent while the anterior tibial does
continue to get flow halfway down the calf though may have several areas
of chronic total occlusion with bridging collaterals.
Based on sheath angiography it was deemed amenable to vascular closure.
Hemostasis was achieved with a 6-French Exoseal device plus adjunctive
manual compression.