Question Angioplasty-carotid/subclavian

dtruelson

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Any ideas on this would be very much appreciated.

DIAGNOSTIC TECHNIQUE:

We obtained retrograde access in the left brachial artery with ultrasound guidance using a micropuncture kit with a 5 Fr sheath. The artery was accessed at a site superficial to the biceps aponeurosis and distal to the crease of the antecubital fossa. The needle was visualized while entering the artery. The microwire was exchanged for a Glidewire Advantage 0.035" wire which was advanced into the aortic arch. The micropuncture sheath was exchanged for a 5 Fr Pinnacle sheath. A Kumpe catheter was placed in the left common carotid artery. Angiography, intervention, followed by completion angiography were undertaken. At case conclusion, the 5Fr Pinnacle sheath was removed and manual pressure was held for 15 minutes. An occlusive dressing and a pediatric knee immobilizer were applied to the left upper extremity. Radial and brachial pulses were palpable; the forearm was soft without signs of a hematoma. The patient was safely transported to the recovery area.

DIAGNOSTIC SUPERVISION INTERPRETATION: The access site was imaged and the microwire was confirmed to be in the left brachial artery. Angiographic imaging confirmed a stenosis at the proximal anastomosis of the left carotid-subclavian BPG. Balloon angioplasty was performed with resolution of a visible waist at nominal balloon pressure. On completion angiogram, the proximal anastomosis had an increased filling diameter.


INTERVENTION: Using a 5 Fr Pinnacle sheath, a GWA glidewire was advanced into the aortic arch. Transduced pullback pressures demonstrated a pressure gradient of only 13 mm Hg; however visual stenosis was seen on DSA imaging obtained within the stent. The patient was anticoagulated with 1000 units of heparin. A 7x20x75 Mustang balloon was positioned across the stenosis using a SmartMask. The balloon was inflated for 2 minutes in the common carotid and the proximal half of the bypass. Upon inflation, resolution of a waist was observed. Follow up angiogram demonstrated an excellent result with <30% residual stenosis. The remaining stenosis was attributed to the anastomotic suture line. Pullback pressures were again obtained and proved variable; this was attributed to graft movement with heartbeat.


IMPRESSION: Successful primary-assisted patency of proximal anastomosis of L carotid-subclavian artery PTFE bypass.
 

dtruelson

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Thanks Jim, I get confused whether I should use 36215 or the 36222.....etc. Is it because they did diagnostic angiogram so we can code an 36222 with an intervention. And if they don't do diagnostic angiogram we would code the 36215 and 37246?
 

Jim Pawloski

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You got it! Can bill for a dx. exam prior to intervention, but if there was a dx. exam done previously, then you only bill for the catheter code and intervention. But only if the catheter code is not part of the intervention.
 
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