carelitz
Guest
Well this is a new one to me. Anyone have any idea what the codes would be? Any insights would be appreciated. Thanks!
So far I have:
75710 2659RT (RT hypogastric artery angiogram)
36245 (cath placement for above)
And then... not so sure.
PROCEDURE PERFORMED: Right hypogastric artery angiogram, unsuccessful
attempt of catheterization of the collateral branches of the lumbar artery
for type 2 endoleak and intention of coiling.
INDICATIONS FOR PROCEDURE: This is a gentleman with known
history of AAA, status post endovascular repair 3 years ago. He had
followup ultrasound, which demonstrated increase in the size of his aortic
aneurysm sac and initially had suspected type 3 endoleak by ultrasound.
He also has known stage III chronic renal insufficiency, obesity and
peripheral vascular disease. We brought him for peripheral angiogram on
12/23/2020, which showed no evidence of type 3 endoleak, there was small
fusiform aneurysm of the right hypogastric artery, and there was evidence
of a collateral branch taken off posterior division of the right
hypogastric artery, and directly connecting to the lumbar artery and into
the aneurysmal sac consistent with type 2 endoleak. Pros and cons of
coiling procedure of the endoleak were discussed with the patient, consent
was obtained.
TECHNIQUE: Arterial access was obtained to the right common femoral
artery with a modified Seldinger technique, micropuncture kit, and direct
ultrasound visualization, and 6-French sheath was used. We then initially
used a 5-French glide Cobra catheter for initial angiogram, and then used
a 6-French Cobra guide followed by use of the 6-French IM guide for the
interventional part of the procedure. The patient received
anticoagulation with 7000 units of heparin, we aim for ACT more than 160,
and at the end of the procedure, received 10 mg of protamine and sheath
was pulled.
Moderate sedation was provided with IV Versed 1 mg, and fentaNYL 50 mcg,
which was delivered by cath lab registered nurse, the blood pressure,
saturation, heart rhythm and rate were continuously monitored. This was
performed under my direct supervision.
Blood loss was negligible.
There were no immediate complications. Manual management of access site
was provided, the local anesthesia for the access site including 10 mL of
2 percent lidocaine.
HEMODYNAMICS: Arterial pressure was 140/70 mmHg.
RIGHT HYPOGASTRIC ARTERY ANGIOGRAM:
1. There is a covered stent, which is an extension of bifurcating graft
in the abdominal aorta covering most distal right common iliac artery.
2. There is proximal fusiform aneurysm, which measures about 18-20 mm in
diameter without any evidence of leak or rupture. There is branch
originated as a part of posterior division, from the aneurysmal dilatation
of the proximal right internal iliac artery with type 2 endoleak directly
connecting to the lumbar artery, with evidence of retrograde flow to the
abdominal aortic aneurysm sac. Otherwise, hypogastric artery beyond the
aneurysmal portion has 3 branches, 1 of posterior division and 2 of
anterior division, which otherwise show no significant connection to the
abdominal aortic aneurysm, no significant stenosis and no aneurysm.
3. The proximal right external iliac artery is a large vessel without
evidence of stenosis or aneurysm.
COILING ATTEMPT OF THE BRANCH OF THE RIGHT HYPOGASTRIC ARTERY: We
initially placed the 6-French Cobra guiding catheter to the bifurcation of
the right iliac artery, and then with minimal manipulation of the tip of
the guiding catheter was navigated to the proximal right hypogastric
artery, then initially I tried 180 cm Whisper extra support wire in an
attempt to cannulate the collateral branch to the lumbar artery, that was
unsuccessful, we then attempted V18 wire, which was also unsuccessful,
attempts were made with multiple manipulations and advancement of the
Cobra guide catheter in the proximal portion of the hypogastric artery to
provide additional and better support for the visualization, and wiring of
the branch of the hypogastric artery.
Then, I attempted the 0.014 Advantage wire, but also was not able to
cannulate the branch.
Then, over the 180 cm J wire, we exchanged the guiding catheter to the
6-French 65 cm IM catheter, which appeared to provide excellent direction
and support for the ambulated vessel; however, I again tried to wire the
vessel with a Whisper wire, V18 wire, and Advantage 0.014 wire, and
despite multiple attempts, we were unsuccessful.
The patient has chronic renal insufficiency, we did 60 mL of contrast use,
also we reached about 5 mCi on the radiation, and because of these
limitations, procedure was stopped.
There were no immediate complications, the blood loss was 10 mL.
CONCLUSIONS:
1. Status post EVAR for AAA, with type 2 endoleak from the posterior
division branch from the right hypogastric artery.
2. Unsuccessful attempt of the catheterization and coiling of the
endoleak type 2 from the right hypogastric artery to the lumbar artery and
aneurysmal sac, unable to wire the vessel.
So far I have:
75710 2659RT (RT hypogastric artery angiogram)
36245 (cath placement for above)
And then... not so sure.
PROCEDURE PERFORMED: Right hypogastric artery angiogram, unsuccessful
attempt of catheterization of the collateral branches of the lumbar artery
for type 2 endoleak and intention of coiling.
INDICATIONS FOR PROCEDURE: This is a gentleman with known
history of AAA, status post endovascular repair 3 years ago. He had
followup ultrasound, which demonstrated increase in the size of his aortic
aneurysm sac and initially had suspected type 3 endoleak by ultrasound.
He also has known stage III chronic renal insufficiency, obesity and
peripheral vascular disease. We brought him for peripheral angiogram on
12/23/2020, which showed no evidence of type 3 endoleak, there was small
fusiform aneurysm of the right hypogastric artery, and there was evidence
of a collateral branch taken off posterior division of the right
hypogastric artery, and directly connecting to the lumbar artery and into
the aneurysmal sac consistent with type 2 endoleak. Pros and cons of
coiling procedure of the endoleak were discussed with the patient, consent
was obtained.
TECHNIQUE: Arterial access was obtained to the right common femoral
artery with a modified Seldinger technique, micropuncture kit, and direct
ultrasound visualization, and 6-French sheath was used. We then initially
used a 5-French glide Cobra catheter for initial angiogram, and then used
a 6-French Cobra guide followed by use of the 6-French IM guide for the
interventional part of the procedure. The patient received
anticoagulation with 7000 units of heparin, we aim for ACT more than 160,
and at the end of the procedure, received 10 mg of protamine and sheath
was pulled.
Moderate sedation was provided with IV Versed 1 mg, and fentaNYL 50 mcg,
which was delivered by cath lab registered nurse, the blood pressure,
saturation, heart rhythm and rate were continuously monitored. This was
performed under my direct supervision.
Blood loss was negligible.
There were no immediate complications. Manual management of access site
was provided, the local anesthesia for the access site including 10 mL of
2 percent lidocaine.
HEMODYNAMICS: Arterial pressure was 140/70 mmHg.
RIGHT HYPOGASTRIC ARTERY ANGIOGRAM:
1. There is a covered stent, which is an extension of bifurcating graft
in the abdominal aorta covering most distal right common iliac artery.
2. There is proximal fusiform aneurysm, which measures about 18-20 mm in
diameter without any evidence of leak or rupture. There is branch
originated as a part of posterior division, from the aneurysmal dilatation
of the proximal right internal iliac artery with type 2 endoleak directly
connecting to the lumbar artery, with evidence of retrograde flow to the
abdominal aortic aneurysm sac. Otherwise, hypogastric artery beyond the
aneurysmal portion has 3 branches, 1 of posterior division and 2 of
anterior division, which otherwise show no significant connection to the
abdominal aortic aneurysm, no significant stenosis and no aneurysm.
3. The proximal right external iliac artery is a large vessel without
evidence of stenosis or aneurysm.
COILING ATTEMPT OF THE BRANCH OF THE RIGHT HYPOGASTRIC ARTERY: We
initially placed the 6-French Cobra guiding catheter to the bifurcation of
the right iliac artery, and then with minimal manipulation of the tip of
the guiding catheter was navigated to the proximal right hypogastric
artery, then initially I tried 180 cm Whisper extra support wire in an
attempt to cannulate the collateral branch to the lumbar artery, that was
unsuccessful, we then attempted V18 wire, which was also unsuccessful,
attempts were made with multiple manipulations and advancement of the
Cobra guide catheter in the proximal portion of the hypogastric artery to
provide additional and better support for the visualization, and wiring of
the branch of the hypogastric artery.
Then, I attempted the 0.014 Advantage wire, but also was not able to
cannulate the branch.
Then, over the 180 cm J wire, we exchanged the guiding catheter to the
6-French 65 cm IM catheter, which appeared to provide excellent direction
and support for the ambulated vessel; however, I again tried to wire the
vessel with a Whisper wire, V18 wire, and Advantage 0.014 wire, and
despite multiple attempts, we were unsuccessful.
The patient has chronic renal insufficiency, we did 60 mL of contrast use,
also we reached about 5 mCi on the radiation, and because of these
limitations, procedure was stopped.
There were no immediate complications, the blood loss was 10 mL.
CONCLUSIONS:
1. Status post EVAR for AAA, with type 2 endoleak from the posterior
division branch from the right hypogastric artery.
2. Unsuccessful attempt of the catheterization and coiling of the
endoleak type 2 from the right hypogastric artery to the lumbar artery and
aneurysmal sac, unable to wire the vessel.
