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Peripheral Vascular Coding

Parul Posted Mon 03rd of December, 2012 19:42:35 PM

Hi, Could you please help code this op-note. I would really appreciated it. Thanks in advance.

PROCEDURE: Peripheral angiogram with angioplasty and atherectomy of the left DP trunk, as well as angioplasty and stenting of the right external iliac artery.

INDICATION: Lifestyle limiting claudication with history of prior stenting.

PROCEDURE NOTE: Consent was obtained. The patient was prepped and draped in the usual sterile fashion. Thereafter, using local anesthesia, the right femoral artery was accessed and a 5 French sheath inserted. Next, a 5 French IM catheter was advanced to the contralateral iliac artery on the left side, using a Wholey wire to cross a high-grade lesion in the external iliac artery on the right side.
The catheter was then advanced to the level of the external iliac artery on the left side and subsequently a guide catheter was placed up to the level of the left SFA artery for angiograms. Next, angiography of the right external iliac artery and the right lower extremity was done through the sheath. Thereafter, the results were reviewed and they revealed bilateral common iliac calcification with mild disease.
Bilateral internal iliac arteries had severe disease with occlusion of the left internal iliac artery filling with collaterals and disease on the right internal iliac artery. The right external iliac artery had an 80% stenosis in its proximal portion. The right common femoral artery had mild-to-moderate disease of about 40% to 50% stenosis. There were stents in the right SFA and right popliteal artery, both of which were widely patent. There was also a stent in the right anterior tibial artery which was patent. The right posterior tibial and peroneal arteries are occluded.
On the left side, the patient has a patent stent in the left SFA and the left popliteal. The left tibioperoneal trunk has a stent with high-grade stenosis with a short segment of 100% occlusion. Below the knee, the patient has runoff from a single peroneal artery with occlusion of the anterior tibial and posterior tibial arteries. Distally, the dorsalis pedis artery filled from collaterals. The sheath in the groin was then changed to a 6 x 50 mm Destination. Right groin was changed to a long 6 x 65 mm Destination which was placed in the distal SFA. Further angiography was done to identify the lesion. Next, the lesion was crossed with a Fielder XT wire and a 0.014 Quick-Cross. Next, the wire was changed to a long run-through wire over which a 1.4 laser atherectomy was done to the occlusion in the tibioperoneal trunk. Thereafter, an AngioSculpt 3.5 x 20 mm balloon was used. Post-angioplasty, there was no residual stenosis and there was excellent single vessel runoff with brisk filling of the collaterals to the distal dorsalis pedis. Next, a check angiogram was done to confirm flow in the remainder of the left distal SFA popliteal artery. The sheath was then changed to a short 6 French sheath, and a 6 x 20 balloon was used to dilate the right external iliac artery which was then subsequently stented with a 7 x 28 balloon expandable stent. This was dilated to up to 10 atmospheres with excellent position and good result. Post-angioplasty angiogram revealed widely patent flow through the SFA, popliteal, and anterior tibial arteries to the dorsalis pedis. The patient was then safely transferred to the floor. The patient was given heparin for the procedure and ACT measured per protocol, keeping it around 250. The sheath was to be removed on the floor in a few hours.

CONCLUSIONS: 1. Occlusion of the left tibioperoneal trunk with single-vessel runoff with successful atherectomy and angioplasty of the tibioperoneal trunk stent.
2. Successful angioplasty and stenting of a high-grade 80% stenosis in the right external iliac artery.

SuperCoder Answered Tue 04th of December, 2012 18:02:47 PM


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