I came up with:
75625, 37226
I70.202, I70.92, Z86.79, Z95.820

Please let me know what I am missing here. Thank you.

Postoperative Diagnoses:
1. Progressive and rapid onset of left calf and knee claudication.
2. New total occlusion of the proximal SFA with reconstitution at the knee seen on CT angiogram.
3. Extensive history of peripheral vascular disease with previous bilateral iliac stenting.
4. Status post successful recanalization with drug-coated balloon angioplasty and stenting of the proximal to mid distal SFA on the left.

Procedure Performed:
1. Right femoral artery access.
2. Distal abdominal aortography with evaluation of bilateral iliac stents.
3. Crossover selective intubation of the left iliac artery.
4. Selective angiography of the common femoral, superficial femoral artery and trifurcation vessels.
5. Placement of crossover sheath right femoral artery to left external iliac artery.
6. Successful recanalization with angioplasty of left superficial femoral artery.
7. Drug-coated balloon angioplasty of the left SFA from proximal occlusion to mid vessel.
8. Stenting of the left superficial femoral artery from proximal to mid distal vessel.
9. Completion angiography.
10. Perclose repair of right femoral arteriotomy site.

Complications:
None.

Description of Procedure:
Informed consent had been obtained. The patient was brought to the special procedures laboratory and placed on the special procedures table. IV conscious sedation was carried out with fentanyl and Versed. For amounts given, please see nursing notes. The right groin site was sterilely prepped and draped in the usual fashion. The right groin was infiltrated with 1% Xylocaine for adequate local anesthesia. Following this, the right femoral artery was cannulated with a 6-French hemostatic introducer sheath. We had to dilate with the introducer dilator because of subcutaneous scarring. The sheath went in easily at that point. At this time, a 6-French pigtail catheter was placed in the distal abdominal aorta. Abdominal aortography was carried out in the AP projection demonstrating bilateral iliac arteries, bilateral common femoral arteries.

At this time, we removed the pigtail catheter. We then used a soft catheter, 5-French, to achieve selective intubation of the left iliac artery. We then did selective angiography of the left common femoral artery, left superficial femoral artery with imaging down to the trifurcation vessels. At this time, we planned our intervention and attempt at recanalization of the SFA. At this time, we advanced a 0.035 Terumo Glidewire through the soft catheter, removed the soft catheter. We then attempted to bring in a Kumpe catheter, it would not cross over at the bifurcation. At this time, we brought in a 6-French Navicross crossover catheter. We were able to advance it down to the level of the common femoral artery. At this time, with the Terumo wire, we attempted to cannulate the SFA through the proximal occlusion. We did obtain a dissection track with this wire, we pulled it back. Angiograms to the Navicross demonstrated that we were not across the true lumen. At this time, we then brought in a 0.018 Asahi Astato 30 x 300mm. We brought this wire in and with some persistence, we were able to cross the total occlusion and gained access to the proximal to mid SFA. We then advanced carefully the Navicross into the proximal SFA and we were able to advance it without difficulty down to the mid SFA. We did an angiogram through the Navicross demonstrating good position. At this time, we placed our Terumo wire through the Navicross artery and into the distal superficial femoral artery and across the popliteal artery and into the anterior tibial artery. At this time, we removed the Navicross crossover sheath. We then brought in our balloon. Our initial balloon was a 4 x 80mm EverCross balloon. We did a series of inflations beginning distally extending up proximally to cover the extent of the disease in the SFA. At this time, we pulled the balloon back. Follow up angiogram at this time demonstrated restoration of flow antegrade into the SFA. There was still significant residual stenosis in the proximal SFA. With a history of restenosis of the iliac arteries, I felt that we had to use every measure possible to limit restenosis in the SFA. At this time, we brought in a Medtronic drug-coated balloon dilating catheter IN.PACT Admiral balloon. It was 5 x 150 mm in length. We brought this balloon in and placed it at the proximal lesion extending as far distally as we felt we needed to go. We then inflated this balloon at nominal inflation pressures for a total dwell time of 3 minutes as per manufacturer’s recommendations. At this time, we deflated the balloon and removed it from the body. Follow up angiograms demonstrated good result at the balloon with restoration of flow, but we wanted to proceed on with stenting of the mid distal and proximal SFA. At this time, we brought in our first stent, which is for the distal segment. It was a 5 x 120 mm EverFlex stent. We brought the stent in to cover the distal extent of the lesions and deployed the stent in the standard fashion. Following this, we removed the stent delivery system. Follow up angiogram demonstrated excellent result at the mid distal segment with good runoff achieved. At this time, we brought in our second stent to cover the mid vessel, which was an EverFlex 6 x 100 mm. The stent was brought in and was allowed overlap with the distal stent. Good position was confirmed. Once the stent was adequately positioned, the stent was deployed in the standard fashion. We then removed the stent delivery device. We had not covered the proximal lesion properly. At this time, we brought in our final stent with was an EverFlex 6 x 40 stent. We allowed adequate overlap with a mid vessel stent and cover the proximal lesion successfully. It was deployed in the standard fashion. At this time, we reintroduced our 5 x 150 mm Admiral balloon dilating catheter to use as a post-development balloon dilation catheter. We brought the catheter in, did a series of inflations going from distal to proximal with good balloon resolution of any wasting and no residual wasting seen on the stent profile. At this time, follow up angiogram was performed. We demonstrated widely patent distal vessel with trifurcation intact, popliteal artery was without disease, and had three-vessel runoff to the foot. We also demonstrated complete resolution of the long segment occlusion of the mid to proximal SFA with excellent results achieved. There was no residual stenosis noted. No evidence of dissection or clot. At this time, the guidewire was removed. The crossover sheath was removed and Perclose closure device was used for hemostasis of the right femoral artery access. The patient tolerated this procedure well. There were no complications encountered.

Findings:
Abdominal aortography: Distal abdominal aortography demonstrates some mild stenosis of the proximal stents bilaterally, no more than 30%. The common iliac stents and the external iliac stents are widely patent. The left external iliac artery is patent and there appears to be normal flow in the right external iliac artery.

Common femoral arteries: The common femoral arteries are widely patent bilaterally. There is minimal 30% plaquing of the right common femoral artery, but no evidence of obstructive lesions.

Left thigh angiography: The common femoral artery bifurcates into the deep profunda vessel and the superficial femoral artery. The superficial femoral artery is totally occluded within 1 cm of its origin. There is a long segment of total occlusion with significant calcification in the vessel extending down. The profunda artery is widely patent. There is a 30% distal stenosis. The superficial femoral artery reconstitutes distally immediately above Hunter’s canal. The popliteal artery fills normally without evidence of obstructive lesion. There was slow three-vessel runoff below the knee demonstrated.

Post-angioplasty and stenting procedure: Following the above described angioplasty and stent procedure, the proximal SFA stenosis reduced to 0% residual stenosis. The remainder of the SFA stenoses are resolved completely. There is a normal vessel distally at Hunter’s canal, a normal popliteal artery and three-vessel runoff below the knee.

Conclusions: Severe obstructive disease of the left superficial femoral artery, status post successful recanalization and stenting of this vessel with use of drug-coated balloon for the proximal, mid lesion as described above.