Cats3
Contributor
Is there anyone who can help me with the following? I have 37242, 36251, 75736-26, but I am not thinking this is correct. Any help would be great. Thank you in advance:
male with history of abdominal aortic aneurysm status post stent graft placement in 2018. The follow-up CT abdomen demonstrated type II endoleak, status post endovascular embolization of the IMA, IMA branches and distal arc of
riolan. 7-month surveillance CTA demonstrated new type II endoleak. Patient presented to IR for the percutaneous transhepatic abdominal endoleak sac injection and embolization of the endoleak and feeder arteries with conscious sedation.
Medications:
1. Versed 6 mg IV
2. Fentanyl 200mcg IV
3. Lidocaine 2% for local anesthesia 17 ml
Upper extremity IV was used. Patient underwent continuous physiologic monitoring throughout the procedure. Conscious sedation was administered and monitored by me with total of 180 minutes monitoring time.
Contrast Data: IOPAMIDOL 76 % IV SOLN 50 mL
Fluoroscopy Time: 46.1 Minutes
Total Skin Dosage: 3447.09 mGy
Complications: None
Specimens: None
Estimated blood loss: Minimal
Description: Written informed consent was obtained from patient. Maximum sterile barrier was used. The patient was placed supine.
Preliminary ultrasound of the abdomen demonstrated enlarged abdominal aorta with internal stent graft and no evidence of active flow in sac. Cone beam CT was performed, demonstrating significantly dilated abdominal aorta. Using the needle guidance and
the reconstructed CT images, a 21-gauge 20 cm Chiba needle was advanced into the LEFT lateral aspect abdominal aorta at the level of IMA orifice. No pulsatile blood return was obtained through the needle. Small amount contrast was injected through the
needle demonstrated contrast filling in the endoleak sac. The needle was exchanged for a Greb sheath over the guidewire. Using coaxial technique, a 2.8 French Progreat microcatheter was advanced into the Greb sheath. Contrast was injected to confirm
location.
Multiple coils (penumbra, Ruby, soft, and packing coils) were deployed in the endoleak sac. Contrast was injected, demonstrating most portion of the endoleak sac being thrombosed. There was active flow in the inferior LEFT endoleak sac with outflow into
two arteries, likely being accessory LEFT renal artery and recanalization of the IMA.
In conjunction with a microwire, the Progreat microcatheter was advanced into the accessory LEFT renal artery. Angiogram was performed, demonstrating contrast flowing into the branch of the LEFT kidney. The microcatheter was slightly retracted with the
tip at the junction of the middle and distal third of the accessory LEFT renal artery. Multiple coils (penumbra, POD and packing coils) were deployed in the accessory LEFT renal artery. Post embolization angiogram was performed, demonstrating no contrast
flow into the LEFT kidney.
Multiple attempts to access into the recanalized IMA were unsuccessful due to the tortuosity. A decision was made to embolize the endoleak sac using NCBA glue. Small amount of contrast was injected through the catheter, suspicious for contrast
extravasation. Repeated coned beam CT demonstrated catheter tip was out of endoleak sac.
Endotracheal ultrasound guidance, a second access was obtained through the previous dermatotomy into the endoleak sac. Coned beam CT was performed to confirm the needle tip in the endoleak sac. Using coaxial technique, Progreat microcatheter was advanced
into the Greb sheath. Again, multiple attempts to access into the recanalized IMA were unsuccessful due to the tortuosity. Subsequently, a mixture of NCBA and lipiodol was injected through the sheath into the sac and the track with the sheath retrieved.
Cone beam CT was repeated, demonstrating mixture of NCBA and lipiodol in sac and track. There was contrast density in the retroperitoneal space anterior to inferior aorta and the common iliac arteries. The coned beam CT was repeated for 4 times,
demonstrating no change of the contrast out the contour of the aorta in extension and density.
Homeostasis was obtained using the manual compression. Sterile dressing was applied.
The patient tolerated the procedure well. There was no complications during the procedure. Patient remained stable and transferred back to the previous back.
Multiple hardcopy ultrasound and fluoroscopic images were obtained throughout the procedure and permanently stored in PACS system.
Impression:
1. Direct transabdominal percutaneous injection into the endoleak sac demonstrated endoleak sac and two inflow/outflow vessels, suggestive of accessory LEFT renal artery and recanalization of the IMA.
2. Successful embolization of the endoleak and the inflow/outflow vessels using coils and glue.
3. Postembolization CBCT demonstrated contrast density in the retroperitoneal space anterior to inferior aorta and the common iliac arteries. Repeated coned beam CTs demonstrated no change of the contrast out the contour of the aorta in extension and
density. This may represent contrast injection through the dislodged catheter versus contrast extravasation from endoleak sac. Patient will be admitted and observed for 24 hours. Surveillance CT abdomen and pelvis with and without contrast will be
followed next morning.
male with history of abdominal aortic aneurysm status post stent graft placement in 2018. The follow-up CT abdomen demonstrated type II endoleak, status post endovascular embolization of the IMA, IMA branches and distal arc of
riolan. 7-month surveillance CTA demonstrated new type II endoleak. Patient presented to IR for the percutaneous transhepatic abdominal endoleak sac injection and embolization of the endoleak and feeder arteries with conscious sedation.
Medications:
1. Versed 6 mg IV
2. Fentanyl 200mcg IV
3. Lidocaine 2% for local anesthesia 17 ml
Upper extremity IV was used. Patient underwent continuous physiologic monitoring throughout the procedure. Conscious sedation was administered and monitored by me with total of 180 minutes monitoring time.
Contrast Data: IOPAMIDOL 76 % IV SOLN 50 mL
Fluoroscopy Time: 46.1 Minutes
Total Skin Dosage: 3447.09 mGy
Complications: None
Specimens: None
Estimated blood loss: Minimal
Description: Written informed consent was obtained from patient. Maximum sterile barrier was used. The patient was placed supine.
Preliminary ultrasound of the abdomen demonstrated enlarged abdominal aorta with internal stent graft and no evidence of active flow in sac. Cone beam CT was performed, demonstrating significantly dilated abdominal aorta. Using the needle guidance and
the reconstructed CT images, a 21-gauge 20 cm Chiba needle was advanced into the LEFT lateral aspect abdominal aorta at the level of IMA orifice. No pulsatile blood return was obtained through the needle. Small amount contrast was injected through the
needle demonstrated contrast filling in the endoleak sac. The needle was exchanged for a Greb sheath over the guidewire. Using coaxial technique, a 2.8 French Progreat microcatheter was advanced into the Greb sheath. Contrast was injected to confirm
location.
Multiple coils (penumbra, Ruby, soft, and packing coils) were deployed in the endoleak sac. Contrast was injected, demonstrating most portion of the endoleak sac being thrombosed. There was active flow in the inferior LEFT endoleak sac with outflow into
two arteries, likely being accessory LEFT renal artery and recanalization of the IMA.
In conjunction with a microwire, the Progreat microcatheter was advanced into the accessory LEFT renal artery. Angiogram was performed, demonstrating contrast flowing into the branch of the LEFT kidney. The microcatheter was slightly retracted with the
tip at the junction of the middle and distal third of the accessory LEFT renal artery. Multiple coils (penumbra, POD and packing coils) were deployed in the accessory LEFT renal artery. Post embolization angiogram was performed, demonstrating no contrast
flow into the LEFT kidney.
Multiple attempts to access into the recanalized IMA were unsuccessful due to the tortuosity. A decision was made to embolize the endoleak sac using NCBA glue. Small amount of contrast was injected through the catheter, suspicious for contrast
extravasation. Repeated coned beam CT demonstrated catheter tip was out of endoleak sac.
Endotracheal ultrasound guidance, a second access was obtained through the previous dermatotomy into the endoleak sac. Coned beam CT was performed to confirm the needle tip in the endoleak sac. Using coaxial technique, Progreat microcatheter was advanced
into the Greb sheath. Again, multiple attempts to access into the recanalized IMA were unsuccessful due to the tortuosity. Subsequently, a mixture of NCBA and lipiodol was injected through the sheath into the sac and the track with the sheath retrieved.
Cone beam CT was repeated, demonstrating mixture of NCBA and lipiodol in sac and track. There was contrast density in the retroperitoneal space anterior to inferior aorta and the common iliac arteries. The coned beam CT was repeated for 4 times,
demonstrating no change of the contrast out the contour of the aorta in extension and density.
Homeostasis was obtained using the manual compression. Sterile dressing was applied.
The patient tolerated the procedure well. There was no complications during the procedure. Patient remained stable and transferred back to the previous back.
Multiple hardcopy ultrasound and fluoroscopic images were obtained throughout the procedure and permanently stored in PACS system.
Impression:
1. Direct transabdominal percutaneous injection into the endoleak sac demonstrated endoleak sac and two inflow/outflow vessels, suggestive of accessory LEFT renal artery and recanalization of the IMA.
2. Successful embolization of the endoleak and the inflow/outflow vessels using coils and glue.
3. Postembolization CBCT demonstrated contrast density in the retroperitoneal space anterior to inferior aorta and the common iliac arteries. Repeated coned beam CTs demonstrated no change of the contrast out the contour of the aorta in extension and
density. This may represent contrast injection through the dislodged catheter versus contrast extravasation from endoleak sac. Patient will be admitted and observed for 24 hours. Surveillance CT abdomen and pelvis with and without contrast will be
followed next morning.