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CodeProAl

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I have the following patient that was seen on subsequent days for a deep venous thrombosis of the left iliac system.

Day of procedure 12/01/16

Patient presents to office today with his left leg swollen from the groin all the way down his limb. This began sometime over the weekend per the patient. He was previously scheduled for an ablation procedure in office but did not show. He was supposed to also have further evaluation in the cath lab tomorrow with a venous stent. When he cancelled I reached out to the patient to convince him to come into the office so I could take a look at his leg. It is obvious the left leg is clotted. The patient has a 3+ edema of classic phlegmasia cerulean dolens looking appearance all the way to the groin. I sent the patient from the office to hospital. At the hospital the patients venous evaluation was demonstrated a clot through his entire system on the left side from groin far distally in the popliteal as was visualized. The patient is taken to the Cardiac Cath Lab, placed on his abdomen and the left popliteal vein is entered percutaneously after local lidocaine anesthesia. I called the ultrasound from echo lab to make sure I was sticking the appropriate structure as the venous structure that was identified had a clot in it. I was able to get a wire into the venous structure and get the wire into the iliac system and was satisfied I was in a vascular structure. I then placed a sheath and gave a small dose of contrast, 2ml Isovue distally to make sure I was in the venous structure and of course clot was demonstrated everywhere. At that point, I placed a standard Judkins guidewire and placed a right coronary catheter and did venous angiography slightly higher up into the clot. I then placed Possis AngioJet and used approximately 110 seconds on AngioJet suctioning, this is a size 6-French sheath AngioJet and suctioned all the way from entry site to the iliac system. At that point, I injected. There was better flow but of course still a significant clot is present so I started the patient on a Tpa drip at 2 mg per hour overnight and then will continued on heparin. I holding aspirin and Plavix at the present time. His hematocrit was low coming into the hospital so I will check this again at midnight and again at 6am in the morning.

Plan: give patient heparin and Tpa overnight. in the morning, patient will be evaluated back in the Cath lab and will use a larger AngioJet if a clot is still present. This will of course depend on appearance of the vein in the morning. I believe patient should remain on lifelong anticoagulation forever.

Day of procedure 12/02/16 AngioJet administration of the left superficial femoral vein.

The patient is taken to Cath Lab. The patient was here yesterday and a #6 sheath was left in the left popliteal vein with an infusion catheter. The infusion catheter is removed and a new #6 sheath inserted. Angiography demonstrates the proximal portion of the femoral vein is fairly open but that is only the distal half and above the mid portion of the femoral vein a significant clot remains. I was not able to get a wire into the vein past the midline and my feeling is there is a chronic clot going into the inferior vena cava so I stuck the right popliteal vein with a #6 sheath and angiography was done in the right popliteal through the guide catheter inserted and this was an angled glide and was able to see that the injection into the venous system on the right side. At this point, I upsized to an #8 sheath. AngioJet catheter into the left femoral vein and did approximately 300 seconds of run in the left femoral vein. At the end of the procedure, both sheaths are removed and hemostasis obtained by local pressure. My plan for the patient is to continure heparin therapy and institute anticoagulation permanently.
 
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Jim Pawloski

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I have the following patient that was seen on subsequent days for a deep venous thrombosis of the left iliac system.

Day of procedure 12/01/16

Patient presents to office today with his left leg swollen from the groin all the way down his limb. This began sometime over the weekend per the patient. He was previously scheduled for an ablation procedure in office but did not show. He was supposed to also have further evaluation in the cath lab tomorrow with a venous stent. When he cancelled I reached out to the patient to convince him to come into the office so I could take a look at his leg. It is obvious the left leg is clotted. The patient has a 3+ edema of classic phlegmasia cerulean dolens looking appearance all the way to the groin. I sent the patient from the office to hospital. At the hospital the patients venous evaluation was demonstrated a clot through his entire system on the left side from groin far distally in the popliteal as was visualized. The patient is taken to the Cardiac Cath Lab, placed on his abdomen and the left popliteal vein is entered percutaneously after local lidocaine anesthesia. I called the ultrasound from echo lab to make sure I was sticking the appropriate structure as the venous structure that was identified had a clot in it. I was able to get a wire into the venous structure and get the wire into the iliac system and was satisfied I was in a vascular structure. I then placed a sheath and gave a small dose of contrast, 2ml Isovue distally to make sure I was in the venous structure and of course clot was demonstrated everywhere. At that point, I placed a standard Judkins guidewire and placed a right coronary catheter and did venous angiography slightly higher up into the clot. I then placed Possis AngioJet and used approximately 110 seconds on AngioJet suctioning, this is a size 6-French sheath AngioJet and suctioned all the way from entry site to the iliac system. At that point, I injected. There was better flow but of course still a significant clot is present so I started the patient on a Tpa drip at 2 mg per hour overnight and then will continued on heparin. I holding aspirin and Plavix at the present time. His hematocrit was low coming into the hospital so I will check this again at midnight and again at 6am in the morning.

Plan: give patient heparin and Tpa overnight. in the morning, patient will be evaluated back in the Cath lab and will use a larger AngioJet if a clot is still present. This will of course depend on appearance of the vein in the morning. I believe patient should remain on lifelong anticoagulation forever.

Day of procedure 12/02/16 AngioJet administration of the left superficial femoral vein.

The patient is taken to Cath Lab. The patient was here yesterday and a #6 sheath was left in the left popliteal vein with an infusion catheter. The infusion catheter is removed and a new #6 sheath inserted. Angiography demonstrates the proximal portion of the femoral vein is fairly open but that is only the distal half and above the mid portion of the femoral vein a significant clot remains. I was not able to get a wire into the vein past the midline and my feeling is there is a chronic clot going into the inferior vena cava so I stuck the right popliteal vein with a #6 sheath and angiography was done in the right popliteal through the guide catheter inserted and this was an angled glide and was able to see that the injection into the venous system on the right side. At this point, I upsized to an #8 sheath. AngioJet catheter into the left femoral vein and did approximately 300 seconds of run in the left femoral vein. At the end of the procedure, both sheaths are removed and hemostasis obtained by local pressure. My plan for the patient is to continure heparin therapy and institute anticoagulation permanently.

Good case to code! I would code this,
Day One 36005-lt, 75820, 37187 for angiojet, 37212 for the TPA infusion.

Day Two 36005-rt, 75820-rt, 37188 for angiojet, and 37214 for the cessation of thrombolysis.

HTH,
Jim Pawloski, CIRCC
 
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