Kcronin1122
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can anyone review and tell me if they agree with the following codes.
93597
93567
93565
36011
36012
36216
36217
36218
37241
37241
36005
76937
The procedure included a left and right heart catheterization with oximetry and hemodynamics. Interventional components included occlusion of veno-venous and aorto-pulmonary collaterals.
XX was brought to the cardiac catheterization lab. After all consents were checked and the hold points completed, she was placed in the usual position and was placed under general anethesia by the anesthesia team. The access site was prepared in the usual sterile manner. Vascular ultrasound imaging was utilized to define selected vessel patency. Real-time imaging was used during vascular access attempts, including visualization of needle passage into the vessel lumen, due to need minimize vascular complications. Ultrasound imaging was captured and placed in the medical record. Access was obtained using the Seldinger technique in the right internal jugular with a 5 French sheath, right femoral vein with a 5 French sheath (utilizing hand injection in right femoral vein for verification of patency), and the right femoral artery with a 4 French sheath. After access was obtained and sheaths were placed, a 5 French wedge catheter in the RIJ, 5 French Berman in the right femoral vein, and a 4F pigtail catheter in the right femoral artery were utilized to perform hemodynamic measurements.
Following hemodynamics, angiograms were obtained in the SVC, LV, and aortic root. Venovenous collaterals were identified arising from the inferior left innominate, as well as aortopulmonary collaterals arising from the RIMA and left subclavian. The were three collateral/decompressing veins measuring 2.8 to 3.3 mm in diameter. A 4F Cobra C2 catheter was advanced into the 1st decompressing vein over a 0.035 Wholey wire. A hand angiogram was performed to better identify the decompressing vein before closure. A 5Q Medtronic MVP was prepared and advanced through the Cobra and delivered in a standard fashion. A hand angiogram was performed through the Cobra prior to release of the plug. It showed no residual shunting. The MVP was then released in a stable position. The plug was released in a stable position. The 4F Cobra C2 catheter was removed, and a 4F JB1 catheter was advanced into the 2nd decompressing vein over a 0.035 Wholey wire. A hand angiogram was performed to better identify the decompressing vein before closure. A 5Q Medtronic MVP was prepared and advanced through the Cobra and delivered in a standard fashion. A hand angiogram was performed through the Cobra prior to release of the plug. It showed no residual shunting. The MVP was then released in a stable position. The 4F JB1 catheter was then advanced into the 3rd decompressing vein over a 0.035 Wholey wire. A hand angiogram was performed to better identify the decompressing vein before closure. A 7Q Medtronic MVP was prepared and advanced through the Cobra and delivered in a standard fashion. A hand angiogram was performed through the Cobra prior to release of the plug. It showed no residual shunting. The MVP was then released in a stable position.
Attention was then turned to the aortopulmonary collaterals. The JB1 was removed from the RIJ sheath and advanced retrograde into the right femoral artery sheath. Using the 0.035" Wholey wire, the JB1 was advanced into the RIMA. The wire was removed, and a hand angiogram was obtained demonstrating collateralization to the right lung. A 4 mm x 7 mm 0.035" Azur CX coil was advanced through the JB1 and deployed in the RIMA.. Follow up hand angiogram demonstrated complete occlusion. The JB1 was then advanced into a more proximal AP collateral arising from the right subclavian artery that measured 1.3 mm. Boston Scientific Contour 700-1000 micron embolization particles were then prepared (suspension in 100% contrast) on a separate table. A 2.8F Progreat microcatheter was advanced through the JB1 catheter into the distal collateral. The Renegade microcatheter was used to deliver the particles and contrast suspension until contrast refluxed. Injection was stopped at that point. A 3 mm x 8 cm 0.018" Concerto Detachable Coil was then delivered through the Progreat microcatheter into the proximal collateral. Hand injection at its origin confirmed successful occlusion.
After completion of the procedure, local anesthesia was given at the access site. The sheaths were removed and hemostasis was obtained. Denae was awakened/extubated and transferred to the PACU in stable condition. The estimated blood loss was 5 mL. The total fluoroscopy was DAP 9.8964 Gy-cm2 and Air Kerma 94.19 mGy. 51 ml of contrast were given in total. A total of 1300 units of IV heparin were given throughout the case.
There were no complications.
Catheterization Findings:
Intubated on 21%FiO2
Baseline
Qp = 1.55 L/min (2.67 L/min/m2)
Qs = 3.37 L/min (5.81 L/min/m2)
Rp = 3.23 units (1.87 units x m2)
Rs = 18.11 units (10.50 units x m2)
Qp/Qs = 0.46 : 1 | Rp/Rs = 0.18
Heart Rate: 75 bpm
VO2: 168 ml/min/m2
Hemoglobin: 12.7 gm/dL
Inspired O2: 21%
pH: 7.37
pCO2: 43.0
pO2: 47.0
HCO3: 24.9
Angiography
1. Right femoral vein (21 G Acess needle, AP projection): The right femoral vein is unobstructed, though there is mild proximal narrowing.
2. Right lower pulmonary vein (5F Berman, AP/Lat projection): There is an unobstructed right lower pulmonary vein draining to the left atrium.
3. Left lower pulmonary vein (5F Berman, AP/Lat projection): There is an unobstructed left lower pulmonary vein draining to the left atrium.
4. Glenn (5F Berman, AP/Lat with caudal angulation projections): There is stenosis of the SVC at the Glenn anastomosis, as well as proximal narrowing of the right and left pulmonary arteries. There is normal arborization with normal pulmonary venous return during the levophase. There are multiple venovenous collaterals arising from the SVC-R subclavian junction and coursing anteriorly and inferiorly through the internal mammary veins. In the AP projection, the SVC measures 9 mm, while the SVC at the anastomosis measures 4.6 mm, the proximal RPA measures 6.5 mm, the distal RPA measures 7.8 mm, the proximal LPA measures 3.5 mm, and the distal LPA measures 6.5 mm.
5. Left ventricle (5F Berman, RAO/LAO projections): There is no significant mitral insufficiency. There is a morphologic left ventricle with good systolic function. There is no LVOT obstruction. There is filling of the aortic root, and right and left coronary systems.
6. Aortic root (4F pigtail, AP/Lat projections): There is trace aortic insufficiency. The aortic root is is dilated. Normal origins and course of the right and left coronary arteries, however the coronary arteries are dilated with fistulous connections to the right ventricle. There are no coronary stenoses or bridging. Right dominant coronary circulation. The ascending aorta is dilated. There is a left aortic arch with essentially normal branching of the head and neck vessels, though there appears to be duplication of right carotid artery. There is no coarctation of the aorta. There are collaterals visualized arising from the RIMA and right subclavian to the right lung field.
7. Venovenous collaterals (4F Cobra and JB1, AP/Lat projections): Multiple hand injections obtained in the three venovenous collaterals from the left innominate vein prior to device closure.
8. RIMA (4F JB1, AP): Hand angiogram in the RIMA demonstrates collateralization to the right lung field. After coil occlusion, there is some residual flow through the RIMA.
9. Right subclavian artery collateral (4F JB1, AP projection): There is a small AP collateral arising from the right subclavian artery that measures 1.3 mm and lead to another network of small AP collaterals to the right lung. Following particle and coil embolization, hand angiogram demonstrated no residual flow.
93597
93567
93565
36011
36012
36216
36217
36218
37241
37241
36005
76937
The procedure included a left and right heart catheterization with oximetry and hemodynamics. Interventional components included occlusion of veno-venous and aorto-pulmonary collaterals.
XX was brought to the cardiac catheterization lab. After all consents were checked and the hold points completed, she was placed in the usual position and was placed under general anethesia by the anesthesia team. The access site was prepared in the usual sterile manner. Vascular ultrasound imaging was utilized to define selected vessel patency. Real-time imaging was used during vascular access attempts, including visualization of needle passage into the vessel lumen, due to need minimize vascular complications. Ultrasound imaging was captured and placed in the medical record. Access was obtained using the Seldinger technique in the right internal jugular with a 5 French sheath, right femoral vein with a 5 French sheath (utilizing hand injection in right femoral vein for verification of patency), and the right femoral artery with a 4 French sheath. After access was obtained and sheaths were placed, a 5 French wedge catheter in the RIJ, 5 French Berman in the right femoral vein, and a 4F pigtail catheter in the right femoral artery were utilized to perform hemodynamic measurements.
Following hemodynamics, angiograms were obtained in the SVC, LV, and aortic root. Venovenous collaterals were identified arising from the inferior left innominate, as well as aortopulmonary collaterals arising from the RIMA and left subclavian. The were three collateral/decompressing veins measuring 2.8 to 3.3 mm in diameter. A 4F Cobra C2 catheter was advanced into the 1st decompressing vein over a 0.035 Wholey wire. A hand angiogram was performed to better identify the decompressing vein before closure. A 5Q Medtronic MVP was prepared and advanced through the Cobra and delivered in a standard fashion. A hand angiogram was performed through the Cobra prior to release of the plug. It showed no residual shunting. The MVP was then released in a stable position. The plug was released in a stable position. The 4F Cobra C2 catheter was removed, and a 4F JB1 catheter was advanced into the 2nd decompressing vein over a 0.035 Wholey wire. A hand angiogram was performed to better identify the decompressing vein before closure. A 5Q Medtronic MVP was prepared and advanced through the Cobra and delivered in a standard fashion. A hand angiogram was performed through the Cobra prior to release of the plug. It showed no residual shunting. The MVP was then released in a stable position. The 4F JB1 catheter was then advanced into the 3rd decompressing vein over a 0.035 Wholey wire. A hand angiogram was performed to better identify the decompressing vein before closure. A 7Q Medtronic MVP was prepared and advanced through the Cobra and delivered in a standard fashion. A hand angiogram was performed through the Cobra prior to release of the plug. It showed no residual shunting. The MVP was then released in a stable position.
Attention was then turned to the aortopulmonary collaterals. The JB1 was removed from the RIJ sheath and advanced retrograde into the right femoral artery sheath. Using the 0.035" Wholey wire, the JB1 was advanced into the RIMA. The wire was removed, and a hand angiogram was obtained demonstrating collateralization to the right lung. A 4 mm x 7 mm 0.035" Azur CX coil was advanced through the JB1 and deployed in the RIMA.. Follow up hand angiogram demonstrated complete occlusion. The JB1 was then advanced into a more proximal AP collateral arising from the right subclavian artery that measured 1.3 mm. Boston Scientific Contour 700-1000 micron embolization particles were then prepared (suspension in 100% contrast) on a separate table. A 2.8F Progreat microcatheter was advanced through the JB1 catheter into the distal collateral. The Renegade microcatheter was used to deliver the particles and contrast suspension until contrast refluxed. Injection was stopped at that point. A 3 mm x 8 cm 0.018" Concerto Detachable Coil was then delivered through the Progreat microcatheter into the proximal collateral. Hand injection at its origin confirmed successful occlusion.
After completion of the procedure, local anesthesia was given at the access site. The sheaths were removed and hemostasis was obtained. Denae was awakened/extubated and transferred to the PACU in stable condition. The estimated blood loss was 5 mL. The total fluoroscopy was DAP 9.8964 Gy-cm2 and Air Kerma 94.19 mGy. 51 ml of contrast were given in total. A total of 1300 units of IV heparin were given throughout the case.
There were no complications.
Catheterization Findings:
Intubated on 21%FiO2
Baseline
Qp = 1.55 L/min (2.67 L/min/m2)
Qs = 3.37 L/min (5.81 L/min/m2)
Rp = 3.23 units (1.87 units x m2)
Rs = 18.11 units (10.50 units x m2)
Qp/Qs = 0.46 : 1 | Rp/Rs = 0.18
Heart Rate: 75 bpm
VO2: 168 ml/min/m2
Hemoglobin: 12.7 gm/dL
Inspired O2: 21%
pH: 7.37
pCO2: 43.0
pO2: 47.0
HCO3: 24.9
Angiography
1. Right femoral vein (21 G Acess needle, AP projection): The right femoral vein is unobstructed, though there is mild proximal narrowing.
2. Right lower pulmonary vein (5F Berman, AP/Lat projection): There is an unobstructed right lower pulmonary vein draining to the left atrium.
3. Left lower pulmonary vein (5F Berman, AP/Lat projection): There is an unobstructed left lower pulmonary vein draining to the left atrium.
4. Glenn (5F Berman, AP/Lat with caudal angulation projections): There is stenosis of the SVC at the Glenn anastomosis, as well as proximal narrowing of the right and left pulmonary arteries. There is normal arborization with normal pulmonary venous return during the levophase. There are multiple venovenous collaterals arising from the SVC-R subclavian junction and coursing anteriorly and inferiorly through the internal mammary veins. In the AP projection, the SVC measures 9 mm, while the SVC at the anastomosis measures 4.6 mm, the proximal RPA measures 6.5 mm, the distal RPA measures 7.8 mm, the proximal LPA measures 3.5 mm, and the distal LPA measures 6.5 mm.
5. Left ventricle (5F Berman, RAO/LAO projections): There is no significant mitral insufficiency. There is a morphologic left ventricle with good systolic function. There is no LVOT obstruction. There is filling of the aortic root, and right and left coronary systems.
6. Aortic root (4F pigtail, AP/Lat projections): There is trace aortic insufficiency. The aortic root is is dilated. Normal origins and course of the right and left coronary arteries, however the coronary arteries are dilated with fistulous connections to the right ventricle. There are no coronary stenoses or bridging. Right dominant coronary circulation. The ascending aorta is dilated. There is a left aortic arch with essentially normal branching of the head and neck vessels, though there appears to be duplication of right carotid artery. There is no coarctation of the aorta. There are collaterals visualized arising from the RIMA and right subclavian to the right lung field.
7. Venovenous collaterals (4F Cobra and JB1, AP/Lat projections): Multiple hand injections obtained in the three venovenous collaterals from the left innominate vein prior to device closure.
8. RIMA (4F JB1, AP): Hand angiogram in the RIMA demonstrates collateralization to the right lung field. After coil occlusion, there is some residual flow through the RIMA.
9. Right subclavian artery collateral (4F JB1, AP projection): There is a small AP collateral arising from the right subclavian artery that measures 1.3 mm and lead to another network of small AP collaterals to the right lung. Following particle and coil embolization, hand angiogram demonstrated no residual flow.