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Brachiocephalic Venoplasty

AmandaBriggs

Expert
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250
Location
Coeur d'Alene, Idaho
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I would appreciate any and all help I can get with coding this case! Started out as a lead revision but due to extensive scarring the procedure was not able to be completed. I would like to code 36010 but I feel like there are other codes that I should be capturing and I'm just not finding them in CPT.
Thank you in advance for your help!

DESCRIPTION OF PROCEDURE: The patient was brought into the room in a fasting state and, after informed consent was obtained, he was prepped and draped in the normal sterile fashion. A right-sided venogram was obtained and patency around the leads was confirmed in an AP view and this was checked, there was flow into the right atrium below the leads in the AP view. Therefore, lidocaine was injected over the device. The incision was carried down over the old scar to the level of the device and, without difficulty and with very extreme care taken around the old leads to not cause any damage in the setting of extremely old leads, the device was extracted and the pocket was inspected and care was taken to take out nonvascularized old scarred areas. Then access was obtained without difficulty using the venogram as a landmark. Once the micro sheath was in place, the micropuncture wire was advanced, but once it got to the level of where all 4 leads come together, it would pass no further. I was gentle at this point, but even with multiple approaches and using the micropuncture sheath to try different angles, it was clear that this was not going to pass. Therefore, I placed the sheath as far as I could, removed the micropuncture wire and took another venogram at this point. At this point, there were 2 vessels visible at the level of the 4 leads. It was seen that there was no dye around any of the 4 leads, suggestive of complete encasement of the 4 leads of scar tissue, but there was dye going into the right atrium. There was also a hint of dye going posterior to the right Atrium.
Using progressively larger sheaths, I was able to do a brachiocephalic venoplasty and where I was unable initially to get even a long 6 dilator through this area, through the venoplasty, I was eventually able to get an Attain 9-French sheath through this.
Then, at this point, a series of different sized sheaths and different material wires were used and ultimately with different positioning of sheaths and wires, I was able to get a Glidewire down through with a full 360 degree loop down behind the heart shadow through a Medtronic tool normally used to deliver coronary wires during CS lead placements. Then through this I placed a Super Stiff wire and then over this I was able to get the Attain sheath into place. Through this, attempts were made to place the Glidewire into the CS through various tools and approaches, but clearly the anatomy at this point was not behaving normally and a venogram was taken and indeed I was in a very engorged azygous vein.
This had taken an extreme amount of different approaches and time and, at this point, it was clear that given the amount of time and approaches that we had already tried, that it was not going to be feasible to get into the right atrium from his right side with all the approaches that we had tried and I felt that every option literally was exhausted. I did get 2 more venograms on the way out from different levels trying to discern where the takeoff to the channel into the right atrium was and it was difficult to even visualize at what point this was occurring. It appears as if there is a double right angle takeoff and that entering into the top of the RA is a small channel in the SVC, but there was never any time where any of the 5 wires through any of the 5 different shaped tipped sheaths ever went that away and I approached all of these from literally 4 different angles at the point of the takeoff.
At this point, it was clear that I was unfortunately not going to be available to get into the right atrium from the right arm and we withdrew all of our catheters from the vasculature. I tied a single pursestring knot around the access site. There was good hemostasis. The pocket initially had been enlarged slightly on the medial border and I used a 3-0 Vicryl to tack down that area as there had been a small amount of persistent oozing along that area as well and then I did place a TYRX antibiotic pouch around the device and placed the leads so that the redundant portion of the coil was behind the pacemaker itself and then reapproximated the fascia and subcutaneous tissue and skin using the normal 3-0, 3-0 and 4-0 suture. The patient tolerated the procedure well and was sent to the recovery room in normal and stable condition.

ASSESSMENT AND PLAN:
1. Failed attempt at his coronary sinus upgrade with near complete occlusion of the superior vena cava and the tortuous collateral vessel was unable to be cannulated despite prolonged attempt with an exhaustive permeations of wires and sheaths.
 
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