Jul 22nd, 2015 - JBTOOLEY0723 3
Peripheral vascular disease with rest pain of left lower extremity
It has been 16 years since I have worked for a vascular surgeon and I need help coding my first procedure. The procedure was done in our office and is noted as follows. Any assistance would be greatly appreciated. Thank you.
PREOPERATIVE DIAGNOSIS: Peripheral vascular disease with rest pain of left lower extremity.
PROCEDURES: 1. Percutaneous access of the right common femoral artery. 2. Placement of a catheter within the aorta. 3. Arteriogram of the left lower extremity. 4. Catheter directed atherectomy of left superficial femoral artery. 5. Catheter directed atherectomy of the left popliteal artery. 6. Percutaneous transluminal angioplasty of the left popliteal artery. 7. Percutaneous transluminal angioplasty of the left superficial femoral artery. 8. Percutaneous stent placement to the proximal left superficial femoral artery.
POST OPERATIVE DIAGNOSES: 1. Same a s preoperative diagnoses with the addition of diffuse atherosclerotic disease of the left superficial femoral artery and popliteal artery. 2. Tibial artery disease.
ANESTHESIA: 1 mg. of Versed, 25 mcg. of Fentanyl and local anesthetic to the right groin.
Estimated blood loss approximately 15 mL. Specimens none. Complications none.
DISPOSITION: The patient tolerated the procedure.
After reviewing the patient risks, benefits and possible sequelae of the procedure, she gave written and verbal consent and was taken from the preoperative holding area to the operative suite where she was placed in a supine position on the table. The right groin was prepped and draped in the usual sterile fashion. The patient had the appropriate monitoring devices to monitor heart rate, pulse oximetry and blood pressure. The right groin after being prepped and draped in the usual sterile fashion was accessed under fluoroscopy with a 18 gauge hook needle and a j-wire was then advanced followed by placement of a 6 French sheath and advanced the guidewire into the aorta followed by advancement of the catheter. I performed an angiogram of the aorta and iliac system before advancing the guidewire and selecting out the left iliac material system and fluoroscopy and watched the advancement of the wire down the left superficial femoral artery. The omni catheter was then removed followed by removal of the short 6 French sheath and advancement of a up and over 6 French ansel sheath until it was within the external iliac artery. Though this sheath I performed a runoff of the left lower extremity with the finding of the diffuse atherosclerotic lesions throughout the left superficial femoral artery and popliteal artery. There was some diffuse disease at the tibial arteries as well. I then used an exchange link catheter to swap out for a long fiberwire that was used to perform atherectomy of the left superficial femoral artery using a CSI atherectomy device. Atherectomy of the left superficial femoral artery and popliteal arteries was carried out and a subsequent angiogram showed better luminal gain of both of these arteries. There was still some ares of narrowing within the popliteal and superficial femoral arteries that were greater than 30 percent. Therefore, I advanced a long 5 mm x 150 cm balloon over the wire and angioplastied the popliteal artery and superficial femoral arteries.
A follow up angiogram showed a small area of dissection of the proximal superficial femoral artery that seemed to be flow limiting and contrast was hanging up in this area, therefore I deployed a short 6 mm diameter stent at this location and follow up angiogram showed excellent flow with contrast beyond this lesion with no flow limitations.
I also did a follow up angiogram of the tibial arteries to insure there was no embolization causing occlusion and none was noted. I then removed all devices leaving the wire and a short 6 French sheath in the right common femoral artery. I performed an angiogram to insure good placement of the sheath before deploying a Mynx closure device at the common femoral artery. A good closure was noted as there was very little bleeding coming from the access site. The patient was then carefully transferred to the recovery room where she remained flat on her back for two hours and demonstrating no ongoing bleeding at the time of discharge.