baratii
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Hi All:
Kindly share your thought upon the below case:
On physical examination, the patient has a proximal left upper extremity semicircular arteriovenous graft. There is no palpable thrill. Ultrasound confirms thrombosis.
1% lidocaine was used to anesthetize the skin. Using ultrasound guidance, the arterial limb was accessed
towards the venous outflow and a 6-French introducer sheath was placed. A 5-French Kumpe catheter was introduced and right central venogram and right upper extremity fistulogram from the superior vena cava to the access site was performed. 3000 units of heparin was administered intravenously.
Next, a 5-French Trerotola device was introduced and used to mechanically thrombolyze the arteriovenous graft from the venous anastomosis to the access site. Followup angiogram shows significant clearance of the clot. There is a 40% stenosis in the venous limb and 40% stenosis in the venous anastomosis, both of which resolved after angioplasty with 7.0 mm x 40.0 mm balloon.
Next, attention was turned towards the arterial anastomosis. The venous limb was accessed towards the
arterial anastomosis and a 6-French introducer sheath was placed. The Trerotola device was introduced into the artery central to the arterial anastomosis, deployed, the arterial plug pulled, and the remainder of the arterial limb cleared. Followup angiogram with Kumpe catheter shows restoration of flow; however, there is a recurrent 60% stenosis in the arterial limb and recurrent 60% stenosis in the mid graft. Given that both of these areas of stenosis recurred despite angioplasty less than one month ago (on January 12, 2015), it was elected to stent this area. These areas of recurrent stenosis in the arterial limb and mid graft were successfully stented using an 8.0 mm x 15.0 mm SMART stent with good angiographic result. Stent was post angioplastied with 7.0 mm x 40.0 mm balloon. Followup angiogram shows resolution of the stenosis and good flow.
Next, attention was turned towards the 50% diffuse stenosis of the left brachiocephalic vein. Over a 0.035 wire, the brachiocephalic vein diffuse stenosis was angioplastied with a 12.0 mm x 40.0 mm balloon through an 8-French sheath. A larger balloon was used compared to prior examination (last time used 10.0 mm diameter balloon). Followup left central venogram shows resolution of the stenosis.
All catheters, wires and sheaths were then removed. Hemostasis of the accessed site was achieved using 3-0 absorbable Vicryl sutures with adequate hemostasis achieved. The patient tolerated the procedure without immediate complication and was transferred to postoperative recovery in good condition for observation. The patient was later discharged in good condition.
Impression:
1. THE PATIENT HAD PROXIMAL LEFT UPPER EXTREMITY ARTERIOVENOUS GRAFT, CLOTTED. SUCCESSFUL
MECHANICAL THROMBOLYSIS WAS PERFORMED.
2. RECURRENT 60% STENOSIS IN THE ARTERIAL LIMB, JUST CENTRAL TO A SMALL SIZED ANEURYSM AT THE
ARTERIAL ANASTOMOSIS AND RECURRENT 60% STENOSIS IN THE MID ARTERIOVENOUS GRAFT. THESE
AREAS OF STENOSIS PERSIST DESPITE ANGIOPLASTY LESS THAN ONE MONTH AGO (ON JANUARY 12, 2015).
TODAY, THESE WERE SUCCESSFULLY TREATED WITH STENT PLACEMENT USING 8.0 MM X 16.0 MM SMART
STENT WITH RESOLUTION OF THE STENOSIS AND GOOD ANGIOGRAPHIC RESULT.
3. MILD 40% FOCAL STENOSIS IN THE VENOUS LIMB AND VENOUS ANASTOMOSIS, RESOLVED AFTER
ANGIOPLASTY.
4. DIFFUSE 40% STENOSIS OF THE LEFT BRACHIOCEPHALIC VEIN, RESOLVED AFTER ANGIOPLASTY (LARGER
BALLOON WAS USED TODAY COMPARED TO PRIOR EXAMINATION ONE MONTH AGO).
5. LEFT PACEMAKER WITH LEADS NOTED.
6. OUTFLOW BASILIC AND AXILLARY VEINS ARE WIDELY PATENT. THE REMAINING LEFT CENTRAL VEINS ARE
WIDELY PATENT. NO STENOSIS.
7. IF RETHROMBOSIS RECURS IN A SHORT PERIOD OF TIME (LESS THAN THREE MONTHS), CONSIDERATION
SHOULD BE MADE TO STENT THE VENOUS LIMB/VENOUS ANASTOMOTIC AREAS OF STENOSIS.
8. BRISK FLOW WITH GOOD PALPABLE THRILL RESTORED AFTER PROCEDURE.
9. NO IMMEDIATE COMPLICATIONS.
My Codes are:
37236
36870
35476
35476 - 59
36147
36148
75978
75978 - 59
Is CPT 35476(Angioplasty vein) is included in CPT 37236(Stent - artery) as it performed in the same zone. My question is how the intervantion performed in vein will be included in the intervention performed in artery??
Please advice.
Thanks.
Kindly share your thought upon the below case:
On physical examination, the patient has a proximal left upper extremity semicircular arteriovenous graft. There is no palpable thrill. Ultrasound confirms thrombosis.
1% lidocaine was used to anesthetize the skin. Using ultrasound guidance, the arterial limb was accessed
towards the venous outflow and a 6-French introducer sheath was placed. A 5-French Kumpe catheter was introduced and right central venogram and right upper extremity fistulogram from the superior vena cava to the access site was performed. 3000 units of heparin was administered intravenously.
Next, a 5-French Trerotola device was introduced and used to mechanically thrombolyze the arteriovenous graft from the venous anastomosis to the access site. Followup angiogram shows significant clearance of the clot. There is a 40% stenosis in the venous limb and 40% stenosis in the venous anastomosis, both of which resolved after angioplasty with 7.0 mm x 40.0 mm balloon.
Next, attention was turned towards the arterial anastomosis. The venous limb was accessed towards the
arterial anastomosis and a 6-French introducer sheath was placed. The Trerotola device was introduced into the artery central to the arterial anastomosis, deployed, the arterial plug pulled, and the remainder of the arterial limb cleared. Followup angiogram with Kumpe catheter shows restoration of flow; however, there is a recurrent 60% stenosis in the arterial limb and recurrent 60% stenosis in the mid graft. Given that both of these areas of stenosis recurred despite angioplasty less than one month ago (on January 12, 2015), it was elected to stent this area. These areas of recurrent stenosis in the arterial limb and mid graft were successfully stented using an 8.0 mm x 15.0 mm SMART stent with good angiographic result. Stent was post angioplastied with 7.0 mm x 40.0 mm balloon. Followup angiogram shows resolution of the stenosis and good flow.
Next, attention was turned towards the 50% diffuse stenosis of the left brachiocephalic vein. Over a 0.035 wire, the brachiocephalic vein diffuse stenosis was angioplastied with a 12.0 mm x 40.0 mm balloon through an 8-French sheath. A larger balloon was used compared to prior examination (last time used 10.0 mm diameter balloon). Followup left central venogram shows resolution of the stenosis.
All catheters, wires and sheaths were then removed. Hemostasis of the accessed site was achieved using 3-0 absorbable Vicryl sutures with adequate hemostasis achieved. The patient tolerated the procedure without immediate complication and was transferred to postoperative recovery in good condition for observation. The patient was later discharged in good condition.
Impression:
1. THE PATIENT HAD PROXIMAL LEFT UPPER EXTREMITY ARTERIOVENOUS GRAFT, CLOTTED. SUCCESSFUL
MECHANICAL THROMBOLYSIS WAS PERFORMED.
2. RECURRENT 60% STENOSIS IN THE ARTERIAL LIMB, JUST CENTRAL TO A SMALL SIZED ANEURYSM AT THE
ARTERIAL ANASTOMOSIS AND RECURRENT 60% STENOSIS IN THE MID ARTERIOVENOUS GRAFT. THESE
AREAS OF STENOSIS PERSIST DESPITE ANGIOPLASTY LESS THAN ONE MONTH AGO (ON JANUARY 12, 2015).
TODAY, THESE WERE SUCCESSFULLY TREATED WITH STENT PLACEMENT USING 8.0 MM X 16.0 MM SMART
STENT WITH RESOLUTION OF THE STENOSIS AND GOOD ANGIOGRAPHIC RESULT.
3. MILD 40% FOCAL STENOSIS IN THE VENOUS LIMB AND VENOUS ANASTOMOSIS, RESOLVED AFTER
ANGIOPLASTY.
4. DIFFUSE 40% STENOSIS OF THE LEFT BRACHIOCEPHALIC VEIN, RESOLVED AFTER ANGIOPLASTY (LARGER
BALLOON WAS USED TODAY COMPARED TO PRIOR EXAMINATION ONE MONTH AGO).
5. LEFT PACEMAKER WITH LEADS NOTED.
6. OUTFLOW BASILIC AND AXILLARY VEINS ARE WIDELY PATENT. THE REMAINING LEFT CENTRAL VEINS ARE
WIDELY PATENT. NO STENOSIS.
7. IF RETHROMBOSIS RECURS IN A SHORT PERIOD OF TIME (LESS THAN THREE MONTHS), CONSIDERATION
SHOULD BE MADE TO STENT THE VENOUS LIMB/VENOUS ANASTOMOTIC AREAS OF STENOSIS.
8. BRISK FLOW WITH GOOD PALPABLE THRILL RESTORED AFTER PROCEDURE.
9. NO IMMEDIATE COMPLICATIONS.
My Codes are:
37236
36870
35476
35476 - 59
36147
36148
75978
75978 - 59
Is CPT 35476(Angioplasty vein) is included in CPT 37236(Stent - artery) as it performed in the same zone. My question is how the intervantion performed in vein will be included in the intervention performed in artery??
Please advice.
Thanks.