This patient has a history of nonhealing lesion and pain in the right foot, previous intervention at Christiana Hospital earlier this year with SFA popliteal angioplasty. He initially had improvement after his procedure in the spring time but has now had recurrent pain and noninvasive studies have revealed significant distal right SFA stenosis and subtotal occlusion of the anterior tibial vessel. Angiography is requested with possible intervention.
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After obtaining informed consent the patient a 5 French sheath was placed in the left common femoral artery and a 5 French contra catheter was positioned abdominal aorta, aortography was performed. Catheter was then withdrawn and aortoiliac injury gram was performed and the catheter was advanced across the aortic bifurcation into the right common femoral artery selectively over a hydrophilic wire. Selective right lower extremity digital subtraction Angiogram with runoff was performed. After I identification of the lesions in the distal right SFA and ostial segment of the anterior tibial vessel, the original sheath and catheter were exchanged out over a stiff support wire for a 6 French by 65 cm destination sheath which was then positioned into the right SFA selectively. With some difficulty a 0.035 hydrophilic wire was able to be advanced through the subtotal occlusion in the ostial segment of the right anterior tibial vessel with use of a 4 French 120 cm glide catheter with an angled tip. The glide catheter was positioned in the proximal anterior tibial and the 035 wire was exchanged for a 0.014 journey wire. Thereafter scoring balloon angioplasty with a 2.5 followed by a 3.0 mm balloon was performed of the ostial proximal segment of the right anterior tibial and distal popliteal vessel. Angiographic result was excellent with brisk restoration of flow in the right anterior tibial, preservation of flow in the tibioperoneal trunk peroneal and proximal posterior tibial vessels as well. Noncritical disease in the distal popliteal was unchanged. Thereafter scoring balloon angioplasty was performed of the distal SFA proximal popliteal stenosis at the abductor canal, at the superior aspect of the patellar shadow. 5 mm scoring balloon angioplasty was performed followed by placement and application of a 6 mm x 60 mm Lutonix drug-eluting stent, 28 atm pressure. After prolonged drug application and balloon removal angiographic result was excellent with brisk runoff down 3 vessel proximally, anterior tibial vessel patent as well as the peroneal to the ankle with distal occlusion of the posterior tibial. The sheath was then removed to the left iliofemoral system and iliofemoral angiography on the left revealed the sheath in the common femoral artery and closure was obtained with a Mynx closure device without complication.
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Hemodynamics:
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Central aortic pressure 120/70.
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Diagnostic digital subtraction angiography:
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Abdominal aorta was patent no ectasia no aneurysm, 2 left renal artery single right renal artery patent celiac SMA and inferior mesenteric arteries. Aortic bifurcation was patent with patent common internal and external iliac vessels bilaterally.
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On the left common femoral vessel was patent with patent proximal left SFA and deep femoral.
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On the right common deep and superficial femoral vessels were patent. The distal SFA had a calcified tubular narrowing of 80% or greater distant the abductor canal and proximal popliteal. Moderate calcification was present. The mid popliteal was patent across the knee the distal vessel has eccentric stenosis of 50% which appeared nonflow limiting. Immediately below the origin of the anterior tibial vessel was subtotally occluded with TIMI grade one flow into this anterior tibial. The tibioperoneal trunk and peroneal vessels were patent, the peroneal was large and was the major vessel all the way to the ankle. The posterior tibial vessel was patent to its distal one third just above the ankle mortise and was occluded at this point with some bridging collaterals. Anterior tibial vessel beyond its subtotal ostial occlusion was patent to the ankle.
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Intervention:
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As detailed above scoring balloon angioplasty and opening of the right anterior tibial vessel was performed.
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Scoring balloon angioplasty and drug-coated balloon treatment was performed of the distal right SFA proximal popliteal lesion at the abductor canal.
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Summary and conclusions:
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Nonhealing lesion right foot severe ischemia.
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Successful opening of the right anterior tibial vessel, patient now has proximal three-vessel runoff, occlusion of the distal segment of the posterior tibial vessel with large peroneal collateralizing the vessel distally and anterior tibial now patent to the ankle and dorsalis pedis.
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Successful treatment of the right distal SFA stenosis as detailed above with patent popliteal
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Bilateral patent aortoiliac vessels.
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*I was going to code as 75716-xu,75625,37224-rt, 37228-rt but I always get confused whether to code as 75630 instead of 75716,75625 ? or when to code 75630
thanks in advance