This has to be the most difficult peripheral procedure to code

Please help !!

PROCEDURE:

1. Right common femoral artery angiography with runoff.

2. EKOS catheter removal.

3. Intraarterial thrombolysis.

4. Atherectomy, ostial right proximal anastomosis of Cryovein

fem-pop bypass.

5. Cutting balloon atherectomy distal anastomosis of right

fem-pop bypass to tibioperoneal trunk.

6. Percutaneous transluminal angioplasty of right posterior

tibial artery.

7. Possis AngioJet for post intra-arterial thrombolysis with

TPA.

8. Possis AngioJet thrombolysis of right fem-pop bypass graft.

COMPLICATIONS:

None.

INDICATIONS:

Graft occlusion, graft failure, thrombosis of right fem-pop

bypass graft, angiography to assess right fem-pop bypass, post

lysis and EKOS catheter placement.

DESCRIPTION OF PROCEDURE:

This 68-year-old male returns to the endovascular lab for stage

II intervention. The patient is 20 hours post-EKOS catheter

placement, right fem-pop bypass graft, which is noted to be

chronically occluded. The patient is taken to the cath lab on

intravenous heparin and TPA infusion 0.5 mg per hour via EKOS

catheter noted, a 6-French contralateral sheath flexor 45 cm in

place via left groin. The patient is prepped and draped. The

EKOS catheter was removed and angiography was performed via the

flexor sheath with placement of a 100 cm Glidewire. This

demonstrates faint flow through the vein graft to the fem-pop

bypass graft down to the legs. However, significant thrombotic

residue still noted. Placement of a glide catheter down

distally, does demonstrate indeed that the runoff is adequate

from the fem-pop graft to the tibioperoneal trunk with runoff to

a single-vessel posterior tibial artery on the right; however, a

stenosis of the ostium of the right posterior tibial artery is

noted of at least 95%, and this is dilated, utilizing a BMW 300

cm guidewire of 0.014 inch with 2 mm x 10 mm Trek balloon, which

was subsequently exchanged for a flex time cutting balloon

Monorail 2 mm x10 mm, which is utilized for sequential dilations

6, 8 and 10 atmospheres, 30 seconds x3 at the distal anastomosis.

The AngioSculpt PTA scoring balloon catheter 4 mm x 20 mm was

also utilized for the distal anastomosis, which does restore

runoff down to the PTA on the right. This is performed at 8

atmospheres, 10, 12 atmospheres, 20 seconds x 3. The proximal

anastomosis of this fem-pop bypass is performed with a 6 mm x 20

mm AngioSculpt PTA balloon at 6, 8, 12 atmospheres, 20 seconds

each, which does restore grade I flow down the leg. An AngioJet

Ultra Omni catheter 100 cm is then passed down the right leg over

the 0.014 inch guidewire for post thrombolysis with TPA;

additional 2 mg injected and kept in place for 15 minutes.

Subsequently, thrombolysis with clot retrieval is performed with

the same catheter. The final angiograms were then performed.

This demonstrates now patent ostium of this bypass, which is a

patulous vein graft patch without residual thrombus. The mid

vein graft is now noted to have mild luminal irregularity, but

flow has returned to normal down to the tibioperoneal trunk

entrance with runoff to the posterior tibial artery still noted,

however, with significant small vessel disease beyond but much

improved flow. No residual stenoses that warrant further

intervention required. Over an 0.035 inch guidewire, the

6 French catheter flexor Sheath 45 cm is exchanged for a

6-French sheath, 10 cm Cordis placed in the left common femoral artery

and sutured in place. The patient was heparinized throughout the procedure and

maintained an ACT greater than 250 seconds. The heparin infusion

was discontinued. The patient will continue on long-term aspirin

and Plavix. Sheath removal over the next 4 hours as planned. The

patient will return to the ICU for further care.

FINAL IMPRESSION:

Successful revascularization of acute on chronic occlusion

recurrence of patched fem-pop bypass of the right leg with

restored pedal pulses post intervention.

This has to be the most difficult peripheral procedure to code