Hi Danny and thanks so much for your comments. Following is the initial report I referred to, along with info on the subsequent procedure notes I have for this pt. I very much appreciate your feedback and agree that the codes I'm looking to appear to be inconsistent with the documentation, but I can't quite figure out how to get on the right track with this...
Pre & Post Procedure Diagnosis: Symptomatic cerebral venous sinus thrombosis.
DOS: 2-12-13
Indication for the procedure: This is a 52-year-old female who was recently diagnosed with AML and was found to have progressive neurologic deficits leading to a coma and a left-sided stroke with hemorrhagic conversion that is extending on heparin from a cerebral venous thrombosis. She was transferred for endovascular therapy. We discussed the risks, benefits, and alternatives at length with the family and informed consent was obtained.
Description of the procedure: The pt was taken to the angiography suite and placed on the angio table. Intubated/prepped and draped/time-out performed,etc…we turned our attention the right femoral site. We localized anatomical landmarks, and we palpated her femoral pulse. We then accessed the femoral artery with the micropuncture needle and wire, and then we performed a microcatheter angio through a transitional sheath, and we exchanged this for a 5-French short sheath that was double flushed. Then I prepared the heparinized saline drip, connected it to a 5-French Vert cath, navigated over the arch in the left common carotid artery. This was connected to a continuous heparinized saline drip. During the procedure, we did heparinize the pt with an initial bolus of heparin 4000 units, and then we did re-dose her during the case.
Once we accessed the artery, we then accessed the femoral vein on the right side and then placed a 5-French short sheath in the femoral vein and double flushed this sheath and then connected a 5-French Vert cath navigated it into the left jugular vein with a Glidewire.
We first navigated the 5-French Cook Shuttle, and then we exchanged this for a 6-French Cook Shuttle because the Penumbra devices would not take the 5-French Cook Shuttle.
Once the 6-French Cook Shuttle was in place, we prepared the Penumbra 54 and Penumbra 32 and then telescoped these and then navigated them into the jugular vein, sigmoid, transverse sinuses with a ChoICE PT wire. We had difficulty accessing the sagittal sinus give the curve that the left sinus took in relationship to the right. We were able to navigate our catheters into place with a Synchro 2 Standard wire. Once we had our microcatheters in place, we did a venogram from the superior sagittal sinus. We also did a cerebral angiogram from the left common carotid artery injection. We then navigated our catheters into position into the thrombus in the sagittal sinus and infused 5 mg of tPA. We did and angio post infusion of tPA, and then we used the Penumbra devices. We used the separator for the 032 cath and the separator for the 054 cath, and we did use these devices to try to open up the sinus. There was patency through the sinus, although you could see evidence of thrombus. There was flow through the sinus, and at this point we felt like replacing our microcath in position would be the best next step in order to infuse intracerebral venous tPA in the sagittal sinus as it did appear that with our first dose of tPA, we had some improvement. So we exchanged our Penumbra cath for a Prowler Plus microcath. Once it was in position we did an angio with the microcath. We did a cerebral angio from a left common carotid artery injection. We then sewed the catheters into position. We had removed our arterial cath. We left the sheath in the groin and sewed it into position, connected it to a heparinized saline drip. We also connected the 6-French Cook Shuttle to a heparinized saline drip, and then we connected the microcath to the infusion of intracerebral venous tPA in the sagittal sinus and this was at a rate of 1 mg/hour. All these caths were addressed, and the pt was taken back to the ICU.
There is then an interp of x-rays and images (17 of them,) and then the Impression:
Sinus thrombosis most noted in the sagittal sinus. The right-sided transverse and sigmoid sinus on the noninvasive images appears to be hypoplastic and occluded. The pt was treated with cerebral venous sinus tPA in the sagittal sinus and then also mechanical thrombectomy with Penumbra. The sinus does appear to have flow through it. It is slow and we left the micro cath infusing tPA. This was connected and sewn to her groin site and leg to secure in position.
Procedures on the following two days include:
DOS 2-13-13:
1. Right vertebral artery cath and cerebral angiogram.
2. Right common carotid artery cath and cervical angiogram.
3. Select right internal carotid artery cath and cerebral angio.
4. Selective left common carotid artery cath and cervical angio.
5. Selective left internal carotid artery cath and cerebral angio.
6. Microcath angio from the venous system.
DOS 2-14-13:
1. Right common carotid artery cath and cervical angiogram.
2. Select right internal carotid artery cath and cerebral angio.
3. Left common carotid artery cath and cervical angio,
4. Cerebral angiogram performed from a left internal carotid artery injection.
5. Venogram performed from the sagittal sinus.
6. Star closure of the femoral access site and a femoral artery angiogram.
