NancyZ76
Contributor
I am sorry if this is already somewhere. I was hoping some one could help me. I am new to vascular coding and need help with the following Op note.... I'm thinking 75716, 75630 and 36245
PROCEDURES:
1. Percutaneous right femoral arterial access under direct ultrasound
guidance.
2. Cannulation of aorta.
3. Aortogram.
4. Bilateral runoff to the ankles.
INDICATIONS:
The patient is an 82-year-old man with a history of a left ischemic toe. He
underwent ultrasound evaluation and the ultrasound showed abnormality at the
popliteal and distal vessels. He presents now for an angiogram.
DESCRIPTION OF PROCEDURE:
The patient was taken to the angiography suite and placed in a supine
position. Mild sedation was given, and the groins and abdomen were prepped
and draped in a sterile manner. A 1% lidocaine was used to infiltrate the
surgical area. Under ultrasound guidance percutaneously, the right femoral
artery was accessed and a guide wire was inserted under fluoroscopy. Over the
guide wire, a 4-French introducer was placed. Over the guide wire into the
introducer, a 4-French pigtail catheter was inserted and guided to the mid
aorta. An aortogram was performed, the catheter was pulled back to the
bifurcation of the iliac arteries. Bilateral runoff to the ankles was done.
The pigtail catheter was removed. The introducer was also removed and
hemostasis was obtained by direct pressure for 20 minutes. Dressings were
placed and the patient was transferred to the recovery room stable. No
complication was seen.
ESTIMATED BLOOD LOSS:
Minimal.
FINDINGS:
The patient was found to have a torturous aorta, but no hemodynamically
significant lesions within the aorta.
On the right side, the iliac system is patent including the common iliac
artery, the external and internal iliac arteries. The femoral system was also
patent including the common femoral artery, the superficial femoral artery,
and the profunda femoris. The superficial femoral artery had no lesions
within the artery. The above-knee popliteal artery has a small
atherosclerotic change, which caused a 10% narrowing of the above-knee
popliteal artery. The popliteal artery was continuous to the sub-trifurcation
vessels and these included the anterior tibial artery, posterior tibial
artery, and the peroneal artery. These arteries were continuous down to the
ankle.
On the left side, the iliac system was patent including the common iliac,
internal iliac, and external iliac artery. The femoral system was also patent
including the common femoral, the superficial femoral artery, and the profunda
femoris. There were some atherosclerotic changes just above the knee at the
proximal popliteal artery. However, this cause no narrowing of the artery
beyond 5%. The popliteal artery itself was widely patent as well as 3-vessel
runoff to the ankle via the anterior tibial artery, posterior tibial artery,
and peroneal artery. At this time, the patient will follow up for further
discussion of the findings as well as further management of his toe.
PROCEDURES:
1. Percutaneous right femoral arterial access under direct ultrasound
guidance.
2. Cannulation of aorta.
3. Aortogram.
4. Bilateral runoff to the ankles.
INDICATIONS:
The patient is an 82-year-old man with a history of a left ischemic toe. He
underwent ultrasound evaluation and the ultrasound showed abnormality at the
popliteal and distal vessels. He presents now for an angiogram.
DESCRIPTION OF PROCEDURE:
The patient was taken to the angiography suite and placed in a supine
position. Mild sedation was given, and the groins and abdomen were prepped
and draped in a sterile manner. A 1% lidocaine was used to infiltrate the
surgical area. Under ultrasound guidance percutaneously, the right femoral
artery was accessed and a guide wire was inserted under fluoroscopy. Over the
guide wire, a 4-French introducer was placed. Over the guide wire into the
introducer, a 4-French pigtail catheter was inserted and guided to the mid
aorta. An aortogram was performed, the catheter was pulled back to the
bifurcation of the iliac arteries. Bilateral runoff to the ankles was done.
The pigtail catheter was removed. The introducer was also removed and
hemostasis was obtained by direct pressure for 20 minutes. Dressings were
placed and the patient was transferred to the recovery room stable. No
complication was seen.
ESTIMATED BLOOD LOSS:
Minimal.
FINDINGS:
The patient was found to have a torturous aorta, but no hemodynamically
significant lesions within the aorta.
On the right side, the iliac system is patent including the common iliac
artery, the external and internal iliac arteries. The femoral system was also
patent including the common femoral artery, the superficial femoral artery,
and the profunda femoris. The superficial femoral artery had no lesions
within the artery. The above-knee popliteal artery has a small
atherosclerotic change, which caused a 10% narrowing of the above-knee
popliteal artery. The popliteal artery was continuous to the sub-trifurcation
vessels and these included the anterior tibial artery, posterior tibial
artery, and the peroneal artery. These arteries were continuous down to the
ankle.
On the left side, the iliac system was patent including the common iliac,
internal iliac, and external iliac artery. The femoral system was also patent
including the common femoral, the superficial femoral artery, and the profunda
femoris. There were some atherosclerotic changes just above the knee at the
proximal popliteal artery. However, this cause no narrowing of the artery
beyond 5%. The popliteal artery itself was widely patent as well as 3-vessel
runoff to the ankle via the anterior tibial artery, posterior tibial artery,
and peroneal artery. At this time, the patient will follow up for further
discussion of the findings as well as further management of his toe.
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