suela923@aol.com
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I didn't feel I could bill for the viseral angiograms because I don't see where the doctor states what vessel his catheter was in but I am being advised that because he states "selective" viseral angiography in his procedure title it's good enough. Any thoughts? Thanks! Sue
Procedure date: 9/25/14
Preprocedure diagnosis: Suspected bilateral renal artery stenosis.
Post procedure diagnosis: Significant bilateral renal artery stenosis.
Procedure: Abdominal aortography; selective bilateral renal angiography; selective visceral angiography of celiac and SMA; bilateral renal artery stenting.
Access: Right common femoral artery.
EBL: 20 cc.
Complications: None.
Patient presented on an elective outpatient basis in a fasting state. She received protocolled IV fluid pre-hydration given a degree of chronic renal insufficiency. She was prepped and draped in the usual sterile fashion. Access was obtained via the right common femoral artery utilizing a modified Seldinger technique. A 5-French sheath was inserted through which a 5-French pigtail was advanced to the suprarenal abdominal aorta. Aortography with bilateral iliac angiography was performed demonstrating the following:
1. The aorta becomes mildly ectatic in the distal segment beyond the origin of the mesenteric vessels and then tapers to the aortic bifurcation where there is moderate disease.
2. There are bilateral solitary renal arteries without adequate visualization of either vessels ostia.
3. The celiac and SMA are widely patent in this projection while the IMA origin is not well visualized due to overlapping lumbar fixation hardware though distal distributions of this vessel are seen to fill robustly.
4. Bilateral common iliac arteries are moderately diffusely diseased.
5. The left external iliac artery appears to have a significant 70% plus stenosis just after the bifurcation.
Given the inability to visualize the ostia of either renal artery, we proceeded onto selective engagement injection using a 5-French IM catheter. Engaging the right renal artery there is evidence of an eccentric up to 80% stenosis that appeared somewhat calcified just slightly removed from the true ostia in the proximal segment and before the first significant bifurcation. I had a slightly higher degree of difficulty in selectively engaging the left renal artery and in the process we visualized both the left SMA which had significant 60-70% proximal stenosis and then the celiac artery which was widely patent. The left renal artery was eventually successfully engaged utilizing a 6-French IM guide and placement of a choice PT wire into the vessel to secure it into position in order to perform selective angiography. This was all performed after therapeutic anticoagulation with heparin was achieved. On this selective angiogram, there is a 60% true ostial stenosis of the left renal artery.
On the basis of these angiograms in combination with the previously performed magnetic resonance angiography and in the clinical setting of highly refractory hypertension with normal sized kidneys not suggestive of atrophy, it was deemed appropriate to proceed on to intervention. With a 6-French IM guide and choice PT wire already across the left renal lesion, we proceeded on with balloon angioplasty utilizing a 4 mm aviator balloon to nominal pressures. This lesion was then stented utilizing a 4 mm x 15 mm, Palmaz Blue balloon expandable stent deployed again at nominal pressures. The deployment balloon was then withdrawn to protrude into the aorta, and the ostia was flared at slightly higher pressures. Repeat angiography demonstrated 0% residual stenosis with brisk antegrade filling and no evidence of stent or wire related complications. We therefore utilized the same guide to then selectively engage the right renal artery ostia and again placed the choice PT wire across the lesion. This was then predilated utilizing a 5 mm x 30 mm aviator balloon projecting into the aorta at nominal pressures. A 5 mm x 18 mm balloon-expandable stent was then used and deployed at nominal pressures after which the balloon was partially retracted in the aorta and the ostial component of the stent was again flared at slightly higher pressures. Final angiography on this side again demonstrated a well expanded stent with 0% residual stenosis and no evidence of distal stent or wire related complications. The guide was withdrawn over a 0.035 wire, and sheath SideArm angiography was performed demonstrating moderate diffuse disease of the distal right external iliac and right common femoral arteries, however, the point of vascular access within a relatively healthy mid segment of the common femoral and was deemed amenable to vascular closure. Hemostasis was therefore achieved utilizing a 6-French Exo seal device plus adjunctive manual compression.
Procedure date: 9/25/14
Preprocedure diagnosis: Suspected bilateral renal artery stenosis.
Post procedure diagnosis: Significant bilateral renal artery stenosis.
Procedure: Abdominal aortography; selective bilateral renal angiography; selective visceral angiography of celiac and SMA; bilateral renal artery stenting.
Access: Right common femoral artery.
EBL: 20 cc.
Complications: None.
Patient presented on an elective outpatient basis in a fasting state. She received protocolled IV fluid pre-hydration given a degree of chronic renal insufficiency. She was prepped and draped in the usual sterile fashion. Access was obtained via the right common femoral artery utilizing a modified Seldinger technique. A 5-French sheath was inserted through which a 5-French pigtail was advanced to the suprarenal abdominal aorta. Aortography with bilateral iliac angiography was performed demonstrating the following:
1. The aorta becomes mildly ectatic in the distal segment beyond the origin of the mesenteric vessels and then tapers to the aortic bifurcation where there is moderate disease.
2. There are bilateral solitary renal arteries without adequate visualization of either vessels ostia.
3. The celiac and SMA are widely patent in this projection while the IMA origin is not well visualized due to overlapping lumbar fixation hardware though distal distributions of this vessel are seen to fill robustly.
4. Bilateral common iliac arteries are moderately diffusely diseased.
5. The left external iliac artery appears to have a significant 70% plus stenosis just after the bifurcation.
Given the inability to visualize the ostia of either renal artery, we proceeded onto selective engagement injection using a 5-French IM catheter. Engaging the right renal artery there is evidence of an eccentric up to 80% stenosis that appeared somewhat calcified just slightly removed from the true ostia in the proximal segment and before the first significant bifurcation. I had a slightly higher degree of difficulty in selectively engaging the left renal artery and in the process we visualized both the left SMA which had significant 60-70% proximal stenosis and then the celiac artery which was widely patent. The left renal artery was eventually successfully engaged utilizing a 6-French IM guide and placement of a choice PT wire into the vessel to secure it into position in order to perform selective angiography. This was all performed after therapeutic anticoagulation with heparin was achieved. On this selective angiogram, there is a 60% true ostial stenosis of the left renal artery.
On the basis of these angiograms in combination with the previously performed magnetic resonance angiography and in the clinical setting of highly refractory hypertension with normal sized kidneys not suggestive of atrophy, it was deemed appropriate to proceed on to intervention. With a 6-French IM guide and choice PT wire already across the left renal lesion, we proceeded on with balloon angioplasty utilizing a 4 mm aviator balloon to nominal pressures. This lesion was then stented utilizing a 4 mm x 15 mm, Palmaz Blue balloon expandable stent deployed again at nominal pressures. The deployment balloon was then withdrawn to protrude into the aorta, and the ostia was flared at slightly higher pressures. Repeat angiography demonstrated 0% residual stenosis with brisk antegrade filling and no evidence of stent or wire related complications. We therefore utilized the same guide to then selectively engage the right renal artery ostia and again placed the choice PT wire across the lesion. This was then predilated utilizing a 5 mm x 30 mm aviator balloon projecting into the aorta at nominal pressures. A 5 mm x 18 mm balloon-expandable stent was then used and deployed at nominal pressures after which the balloon was partially retracted in the aorta and the ostial component of the stent was again flared at slightly higher pressures. Final angiography on this side again demonstrated a well expanded stent with 0% residual stenosis and no evidence of distal stent or wire related complications. The guide was withdrawn over a 0.035 wire, and sheath SideArm angiography was performed demonstrating moderate diffuse disease of the distal right external iliac and right common femoral arteries, however, the point of vascular access within a relatively healthy mid segment of the common femoral and was deemed amenable to vascular closure. Hemostasis was therefore achieved utilizing a 6-French Exo seal device plus adjunctive manual compression.
