kokomax
Contributor
I am needing help with coding this procedure - I'm thinking 37246-59, 37236, 37221-50 - your help would be greatly appreciated!!! 
| Procedure Name |
| 1. Aortoiliac angiography |
| 2. Shockwave balloon angioplasty of the mid aorta |
| 3. Shockwave balloon angioplasty of the bilateral common iliac arteries |
| 4. Stent supported angioplasty of the mid aorta |
| 5. Stent supported angioplasty of bilateral common iliac arteries. |
| Indication |
| High-grade stenosis of the mid aorta below the renal arteries calcified. High-grade stenosis of bilateral common iliac arteries right more than the left. Heavily calcified vessels. Moderate disease of bilateral external iliac artery is heavily calcified. Severe claudication. |
| Details: |
| After obtaining informed consent, the patient was brought to the Cath Lab. She was prepped and draped in order to obtain a sterile field. Under my supervision the patient was moderately sedated with IV Versed and fentanyl, during the procedure the blood pressure heart rate and pulse ox were continuously monitored by the nurse. My face-to-face moderate sedation time with the patient was 2 hours. The right groin was anesthetized with 1% lidocaine. The right common femoral artery was cannulated using modified sedated technique with a micropuncture kit ultrasound guidance upgraded to a 7 French sheath. Then the left groin was anesthetized with 1% lidocaine. The left common femoral artery was cannulated using modified Seldinger technique with a micropuncture kit ultrasound guidance upgraded to a 6 French sheath, then 2 Perclose devices were redeployed. Then a 10 French sheath was placed through the left common femoral artery. Initially a pigtail catheter was placed into the abdominal aorta and aortoiliac angiography was performed which revealed high-grade stenosis of the mid aorta and the bilateral common iliac arteries. The patient was anticoagulated with IV heparin. So a V18 wire was placed through the right common femoral artery an 014 wire Sparta core wire was placed through the left common femoral artery. An 8 mm / 40 mm shockwave balloon was taken into the mid aorta and multiple treatments were given. Then the balloon was pulled back into the common iliac artery and again balloon angioplasty was performed in the right common iliac artery. Then a 7 mm / 60 mm shockwave balloon was taken into the left common iliac artery and the left external iliac artery were subsequently both vessels were treated. Then a Sparta core wire through the left common femoral artery was exchanged into an Amplatzer wire. We tried to advance the 17 fr delivery sheath of the ovation device however it would not advance despite multiple maneuver due to the moderate disease of the left external iliac artery and the stent that was in the left common iliac artery, subsequently we exchanged that sheet into a 16 French dry seal sheath that went easily to the aorta, will try to upgrade to 18 French dry seal sheath in order to deliver the bifurcating device however the 18 French sheath would not advance. So at this point went back to the 16 French sheath, over the Amplatzer wire a 22/45 mm ovation cuff was deployed in the mid aorta and post dilation was performed with a Q50 balloon. After that the 16 French sheath was exchanged into a 10 French sheath the 2 Perclose sutures were cinched on the sheath to avoid bleeding. And angiography of the left external iliac artery was performed to make sure that there is no extravasation at that level. Following which a supra core wire was placed through the right common femoral artery into the aorta, then I took to cover the stent Lifestream each is 7/58 mm stent and deployed them from the distal end of the cough to the mid common iliac arteries. The deployment was at 12 atm then the stent were postdilated with a 8 mm balloon up to 12 atm. Final angiography was performed that showed 0% residual and TIMI-3 flow distally. At this point a 6 fr Angio-Seal device was deployed through the right common femoral artery good hemostasis was obtained the 10 French sheath was removed the 2 Perclose devices were deployed again into the vessel however there was still bleeding so a third Perclose device was deployed which did not achieve adequate hemostasis a 6 French Angio-Seal device was deployed, better hemostasis was obtained however we had to give protamine to reverse the anticoagulation and manual compression was held with good hemostasis. Pulses were checked distally and there were positive in both limbs. Overall the patient tolerated well the procedure there was no complications. She left the catheterization laboratory hemodynamically stable and neurologically intact. |
| Results: |
| Hemodynamics: |
| 1. Central aortic pressure: 140/80 mmHg. |
| Angiography results: |
| 1. Aortoiliac angiography revealed a calcified aorta that is diseased in the mid aorta there is 70 to 80% lesion that is calcified. Both renal arteries are patent. The right common iliac artery has an eccentric 90% lesion at the bifurcation. The right external iliac artery has moderate disease. The left common iliac artery has a stent that has moderate in-stent restenosis there is moderate disease in the left external iliac artery. |
| Angioplasty results: |
| 1. Status post stent supported angioplasty of the aorta with final angiography revealing less than 30% residual and TIMI-3 flow distally. |
| 2. Status post stent supported angioplasty of both common iliac arteries with final angiography revealing 0% residual and TIMI-3 flow distally. |
| In conclusion successful aortoiliac revascularization the patient will be on aspirin Plavix and statin will admit her overnight for observation. |