I'm wondering if I have too many codes in this OP report, especially selective catherizations and balloon angioplasty's. Is this how it should be coded?
1. Peripheral vascular disease with nonhealing ulcer, right foot.
5. Ischemic cardiomyopathy.
1. Access, left groin.
2. Selective right lower extremity angiogram (catheter in third order branch).
3. Cryoballoon angioplasty, tibioperoneal trunk.
4. Cryoballoon angioplasty, right posterior tibial artery.
5. Cryoballoon angioplasty, right anterior tibial artery x 3.
6. Insertion of self-expanding stent, distal SFA, 7- x 6-mm.
DISPOSITION: The patient was extubated in the operating room and transported to the recovery room in stable condition. Following deployment of stent to the distal SFA lesion, no residual stenosis was noted. The chronic total occlusion, which was noted in the right anterior tibial artery, was opened well and there was good reconstitution and good distal flow. Likewise, the severely diseased right posterior tibial artery and the tibioperoneal trunk also showed good results with cryoballoon inflation and angioplasty.
INDICATIONS: The patient is a very pleasant 68-year-old male who was hospitalized for a nonhealing ulcer involving his right foot. He was receiving hyperbaric oxygen therapy. He was transferred to ----- for further vascular surgery, consultation, and evaluation. The patient had undergone diagnostic angiogram 2 days ago and we identified 60% to 70% stenosis of the distal superficial femoral artery. In addition, there was 100% occlusion of the right anterior tibial artery with delayed reconstitution and severely diseased right posterior tibial artery in 2 separate segments as well as proximal tibioperoneal disease. The peroneal artery was 100% occluded as well, and there was one-vessel runoff to the foot via the posterior tibial artery. Risks and benefits were explained in detail. Options were presented to the patient, and at that point, the patient as well as his wife lean strongly towards endovascular form of treatment. Our game plan would be to do angioplasty and possibly stent these lesions if feasible and allow medical optimization with treatment and in the event the patient does not respond then we may be left with limb salvage distal bypass surgery at a later date.
DESCRIPTION OF PROCEDURE: After successful intubation of general anesthesia, the entire area of the abdomen, bilateral groins, and lower extremities were prepped and draped in the usual sterile fashion. We were able to identify the left common femoral artery and access was achieved with an 18-gauge needle. A starter wire was passed under fluoroscopy and we then used a crossover LIMA catheter, and we were able to successfully cross over to the right common iliac artery. The wire was gently advanced all the way into the right common femoral artery until adequate purchase was obtained. The crossover catheter was then advanced all the way into the common femoral artery. Intravenous heparin was given. The guidewire was removed and this was replaced with a much stiffer Amplatz wire. The tip of the Amplatz wire was carefully noted and with the Amplatz wire in place, we exchanged the crossover catheter for a 7-French crossover destination catheter. The destination catheter was then popped into the common femoral artery. We then used a 4-French glide cath over the Amplatz wire and angiogram was obtained. As mentioned before, there was moderate-to-severe disease involving the distal aspect of the SFA. With the help of the glidewire and a glide cath, we were able to negotiate past the lesion into the distal popliteal artery. Selective angiogram was performed, and the lesions were identified. Our first step was to exchange the 0.035 glidewire for 0.014 thruway wire. With the help of thruway wire, we were able to go past the trifurcation into the proximal tibial trunk. The wire was left in place. The glide cath was removed, and a 2.5 cryoballoon angioplasty was then passed and this was angioplastied x 2. Likewise, the wire was passed distally along the posterior tibial artery and we performed cryoballoon angioplasty x 2 over the severely diseased proximal right posterior tibial artery segment. Once having completed the angioplasty of the tibioperoneal as well as the proximal right posterior tibial artery we pulled the 0.014 wire back and with the glide catheter positioned over the distal popliteal artery, angiogram was obtained and we were very satisfied with the outcome. At this point, we then used the combination of a glide cath along with the 0.014 wire and we were able to get into the anterior tibial artery. As mentioned before, the right anterior tibial artery was 100% occluded and we had to use a different thruway wire as the previously placed wire was nonfunctional. We were able to successfully go across the chronic total occlusion and enter into the distal right anterior tibial artery. With the wire in place, we then used a 2.5-mm cryoballoon at 2 different points. Once having satisfied ourselves with balloon inflation, which was done in 3 different locations, we then used a regular balloon to reestablish flow. Once having completed the angioplasty of all the 3 distal lesions, we pulled the glide cath back and exchanged it for an 0.035 wire. The glide cath was removed back and repeat angiogram of the distal SFA lesion was performed and the extent of the disease process was identified. We then used a self-expanding nitinol express stent. Following deployment of the stent, we did post-deployment balloon dilatation and completion angiogram showed no residual stenosis. We were extremely satisfied with the outcome and the wire and a catheter was removed under direct vision. The 7-French destination catheter was also removed from the left side. Hemostasis was
secured with manual pressure. Protamine was used for reversal. The right foot had strongly pulsatile posterior tibial pulse. The patient was brought to the recovery room in stable condition.
Thank you for your help!!!