Ask Dr. Z

I wanted to get your opinion on the use of the Avinger Ocelot PIXL atherectomy device. I am assuming based on the below op note that this would not be coded separately, as it is being used in a recanalization procedure prior to angioplasty (37224). I know in your IR book you do mention, "Crossing the lesion is bundled with codes 37220-37235. The angioplasty, atherectomy, or stent placement procedure is coded." Is that the case with the below as well? Just want to check to be sure I am advising correctly.

PREOPERATIVE DIAGNOSES: Total occlusion of the left superficial femoral artery involving the entire length along with the total occlusion of the proximal popliteal artery of the right leg. OPERATION PERFORMED: Right femoral arteriogram with distal run-off, recanalization of the superficial femoral artery and popliteal artery using Avinger Ocelot PIXL atherectomy catheter followed by multiple overlap balloon dilatations, then using 4.0 x 100 mm AngioScore AngioSculpt dilatation catheter, followed by using a 6.0 x 200 mm power PowerCross dilatation catheter, then a 6.0 x 200 mm Mustang dilatation catheter. POSTOPERATIVE DIAGNOSES: Total occlusion of the left superficial femoral artery involving the entire length along with the total occlusion of the proximal popliteal artery of the right leg with good recanalization but poor run-off distal to popliteal artery, diffuse disease. PROCEDURE: An informed consent obtained. The patient was taken to cardiovascular laboratory. Under routine sterile precaution, using 1% Xylocaine local anesthesia, the left femoral artery was punctured by the single-wall technique and the size 6 femoral sheath was placed in. The patient was given Angiomax IV bolus followed by an IV infusion according to protocol. A size 5 Omni Flush catheter was introduced along with the Terumo guidewire. The catheter was advanced into the right common femoral artery. The Omni Flush catheter was then substituted by a size 7 Destination sheath which was positioned at the right common femoral artery. Right femoral arteriogram was then obtained with a distal run-off. This revealed total occlusion of the right superficial femoral artery involving the entire length followed by reconstitution of distal popliteal artery. Avinger Ocelot PIXL 135 5-French atherectomy device was introduced along with the 0.014 Floppy guidewire. It was able to advance the atherectomy device with OCT and fluoroscopic guidance to the distal superficial femoral artery. There was a difficult time to advance the distal superficial femoral artery into the popliteal artery. But it was able to pass the 0.014 Floppy guidewire into the popliteal artery and deep peroneal artery. Size 2.0 x 210 mm NanoCross ev3 dilatation catheter was introduced and multiple overlap dilatation carried out to the entire occluded segment by inflating balloon up to 12 atmospheres up to 1 minute of duration. The balloon size was then increased to 3.0 x 210 mm NanoCross ev3 dilatation catheter. Again, multiple overlap dilatation carried out to the entire occluded segment of the superficial femoral artery and proximal popliteal artery by inflating balloon up to 10 atmospheres up to minute-and-a-half duration. Satisfactory opening was noted. Size 4.0 x 100 mm AngioScore AngioSculpt dilatation catheter was introduced and multiple overlap dilatation is carried out to the entire occluded segment. Repeat angiogram; however, showed no significant improvement of the lumen and flow. Size 6 x 200 mm ev3 PowerCross dilatation catheter was then introduced. Multiple overlap dilatation carried out by inflating balloon up to a minute-and-a-half to two minutes. A satisfactory opening was noted. Repeat angiogram revealed good improvementthe the lumen size with good run-off although there is some irregularity noted of the distal superficial femoral artery. Poor distal run-off below the popliteal artery. There is a small deep peroneal artery along with the prior occlusion of the anterior tibial and posterior tibial artery. A size 6 x 200 mm Mustang Non compliant balloon catheter was then introduced. Again, multiple overlap dilatation carried out to the entire length of the superficial femoral artery and proximal segment of the popliteal artery. The final angiogram revealed good patency throughout with no significant residual stenosis or local complication although there is poor distal run-off below the popliteal artery. The destination sheath was then removed and replaced by a size 8 femoral sheath. Left femoral angiogram performed. The common femoral sheath was removed and puncture site was closed with the size 8 Angio-Seal. There were no complications. TOTAL AMOUNT OF CONTRAST: 130 mL of the Isovue. ESTIMATED BLOOD LOSS: About 30 mL. IMPRESSION: Successful recanalization of the totally occluded right superficial femoral artery including entire segment and the proximal, one-half of the right popliteal artery with the successful recanalization using Avinger Ocelot atherectomy device and multiple overlap dilatations using small balloon size up to 6.0 balloon with a good result throughout although there is very poor run-off distally below the popliteal artery as described.