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Resolved Acute-On-Chronic Left Lower Extremity Ischemia with Progressive Rest Pain

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KathyP_3146

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I need reassurance if anyone can help with CPT coding.

I have coded this as 34201, 34203, 35400, 75625, 36245
POSTOPERATIVE DIAGNOSES:
1. Acute-on-chronic left lower extremity ischemia with progressive rest pain.
2. History of T-cell lymphoma, currently in remission.

PROCEDURES PERFORMED:
1. Left superficial femoral artery mechanical thromboembolectomy.
2. Left popliteal artery mechanical thromboembolectomy.
3. Left tibioperoneal trunk mechanical thromboembolectomy.
4. Left anterior tibial mechanical thromboembolectomy.
5. Patch angioplasty of the distal popliteal artery onto the anterior tibialis artery at the takeoff.
6. Left lower extremity selective angiogram plus radiologic supervision and interpretation.
ESTIMATED BLOOD LOSS: 100 mL.
COMPLICATIONS: None apparent.
SPECIMENS: Large amount of organized fresh and old thrombus with white organized thrombus.

INDICATION FOR THE PROCEDURE: The patient is a very pleasant 69-year-old male, who was referred to the vascular clinic in consultation through one of our local emergency departments. The patient reported to me that while vacationing in Colorado approximately 2 months ago, he noticed progressive discomfort on his left lower extremity upon ambulation. He did not initially meet much of the problem since he was actually able to carry on with most of his daily activities without any problems. However, over the past week, the initial claudication, which occurred at 50-100 yards, progressed to less than 20 yards and now is up to the point in which the patient has severe pain at rest, especially at night when he elevates his limb. He has been given narcotic pain medication to try to control the pain; however, the medication does not work for him. After he was seen at the vascular clinic, I noticed that he only had venous signals over his dorsalis pedis on the left lower extremity, whereas the contralateral side had normal palpable distal pulses. The patient was set up to get an urgent CT angiogram of the abdominal aorta with bilateral lower extremity runoff when we realized that he had very ectatic blood vessels on his right lower extremity on examination. I reviewed the study immediately after it was performed. The patient has a complete cutoff of his left superficial femoral artery and the study does not show any distal tibial arteries until the mid calf, where a small anterior tibial artery can be visualized that extends down to the ankle. By the appearance of it appears that the patient has had a thromboembolic event. I have discussed with the patient and his wife the possibilities of an exploration of the popliteal artery with thromboembolectomy of his left lower extremity arteries versus possibility of a femoral-to-tibial bypass. The only problem is that the patient suffers from superficial venous insufficiency and has diffuse varicosities on both lower extremities; and therefore, his greater saphenous vein may not be the best option should he require a bypass. After I discussed with them the benefits and risks of the procedures, they granted consent.

PROCEDURE PERFORMED: As follows: After informed consent was obtained from the patient, the patient was taken to the operating room. He was placed on the operating table in the supine position and general anesthesia was induced. After induction of the general anesthesia, the patient's groins as well as his entire left lower extremity were prepped and draped in the usual sterile fashion. Using a micropuncture set, retrograde access to the right common femoral artery was obtained. The access was secured with a 0.018 wire and a 4-French dilator was passed over the wire. A 0.038 J-wire was advanced to the right iliac system and a 6-French introducer sheath was set in place. A stiff Glidewire was advanced to suprarenal level and an SOS Omniflush catheter was placed above the renal arteries. An angiogram was obtained. The angiogram showed no significant disease of the infrarenal aorta. Both renal arteries were widely patent as well as both common iliac arteries, hypogastrics and external iliac arteries. The SOS Omniflush catheter was then brought back down to the aortic bifurcation and the contralateral left iliac system was engaged with the stiff Glidewire. The SOS Omniflush catheter was then advanced all the way down to the common femoral artery. The stiff Glidewire was replaced by an Advantage wire, which was advanced into the deep femoral artery on that side and a 45 cm 6-French sheath was placed all the way down to the left common femoral artery to aid with angiography. The Advantage wire was removed. Left lower extremity angiogram revealed normal-appearing common femoral artery and femoral bifurcation. There was a complete cutoff of the distal superficial femoral artery with what appeared to be mobile distal thrombus. There was minimal amount of collaterals and I could not visualize any named vessels below the knee. Therefore, I decided to proceed with an exploration of the below-knee popliteal artery.

Using a #10 scalpel blade, an incision in the medial aspect of the left lower leg was made. Incision was then carried through the subcutaneous tissue and superficial fascia with electrocautery. A segment of the long saphenous vein was identified. Some varicosities were identified within the vein. Some branches were divided to try to protect the vein in case we would need it for a bypass. While the superficial fascia was opened up, the popliteal fossa was entered. The popliteal vein was identified. Very carefully, the popliteal vein was separated from the popliteal artery. There appeared to be some subacute inflammatory changes in the area, not typical of an acute thromboembolic event. Very carefully, the popliteal artery was separated. I dissected all the way down to just above the takeoff of the anterior tibialis artery. Proximal and distal control was established. Using a #11 scalpel blade, a longitudinal incision over the popliteal artery was made. Incision was enlarged with the Potts scissors. Large amount of old thrombus was identified. A #4 Fogarty catheter was then passed proximally in 3-4 different passes until the entire thrombus including the organized white thrombus was completely excised and we restored pulsatile flow to the popliteal artery. Distally, a #3 Fogarty catheter was advanced through the tibioperoneal trunk in several occasions dragging a large amount of organized thrombus; however, we obtained only very minimal backbleeding. The tibioperoneal trunk flushed easily with heparinized saline; and therefore, we decided to proceed with a patch angioplasty of the popliteal artery with the hope that we will obtain an angiogram showing us good distal flow. The bovine pericardial patch was then sutured for the angioplasty of the popliteal artery using 6-0 Prolene suture. Prior to completion of the patch angioplasty, the distal popliteal artery was backbled and the proximal was flushed. The patch angioplasty was then completed and the flow was restored. Once the flow was restored, left lower extremity selective angiogram was obtained. Selective angiogram once again showed the normal-appearing common femoral artery as well as the common femoral bifurcation. However, the superficial femoral artery showed only very sluggish flow just above adductor canal. There was no flow into the popliteal artery and there was no flow into the tibial vessels. We decided to revise our patch angioplasty at this point to be able to guide my catheter into the tibioperoneal trunk as well as the anterior tibialis artery, which appeared to be on the CT scan the best possible vessel for a distal runoff. The gastrocnemius was separated from its insertions onto the tibia. The crossing veins of the popliteal vein were then carefully dissected out. This proved to be a very tedious dissection due to the fact that they had subacute inflammatory changes, which plastered up all these veins to the tibioperoneal trunk and distal popliteal artery. Eventually, with a very tedious dissection and much care, we managed to divide these crossing veins, suture ligate them on both sides and divide them. The tibioperoneal trunk was then clearly exposed as well as the takeoff of the anterior tibial artery, which appeared to be a robust vessel. The previous patch was removed, our arteriotomy was then enlarged onto the takeoff of the anterior tibial artery. The #3 Fogarty catheter was then passed once again, this time onto the anterior tibialis artery, obtaining a large amount of organized white clot and a more brisk backbleeding from the anterior tibialis artery. On the tibioperoneal trunk, we were only able to advance the #3 Fogarty catheter down to approximately 10 cm and no further thrombus was removed. We decided to once again attempt a patch angioplasty, at this time directing our patch angioplasty onto the takeoff of the anterior tibialis artery in which we were able to advance the Fogarty catheter all the way down to the ankle. The bovine pericardial patch was then used for a patch angioplasty using 6-0 Prolene sutures. Prior to completion of the patch angioplasty, the anterior tibialis and tibioperoneal trunk were backbled and the popliteal artery was flushed. Patch angioplasty was then completed.
 
I think you have it covered. This is a great one. Can we use it for teaching purposes in one of our student or club webinars?
 
Thanks for your help. Yes you may use this. I always appreciate the great knowledge that you company has.
 
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