margaret fahy
Guru
Hi Guys,
Is anyone out there today who can help me with this one?
Possible codes: 36245,75726,36245-59,75726-59,36011-59,36012,36481,75887...what about the shuntogram? Also, didn't see selective catheterization of renal artery...
Exam: IR Angio Visceral Selective
IR Angio Renal Unilateral Completed: 05/08/2014 4:45 PM
05/08/2014 4:45 PM
Indications:
Diagnosis:Hyperbilirubinemia [782.4 (ICD-9-CM)]<br />Liver mass [573.9 (ICD-9-CM)]
Hyperbilirubinemia [782.4 (ICD-9-CM)]<br />Liver mass [573.9 (ICD-9-CM)]
Reason:8yo with large hepatic lesion, arterial embolization to decrease mass size
LIVER MASS
Interpretation:
CLINICAL HISTORY: History of large hepatic tumor, likely adenoma,
for pre operative portal vein and hepatic vein planning and
possible embolization of tumor.
COMPARISON: CTA 4/22/14, MRI 3/21/14
PROCEDURE TIME: 3 hours
WEIGHT: 24kgs
PROCEDURE: The skin of the right groin was prepped and draped in
sterile fashion. Using US guidance a 21 gauge needle was inserted
in the right common femoral artery. Once arterial blood return
was obtained a .018" Mandril wire was placed into the artery and
advanced to the distal abdominal aorta. The needle was removed
and replaced with a 5 French micropuncture sheath/dilator set.
The wire was sized up to a .035" Newton wire, and a 5 French
vascular sheath was placed into the artery. Via the arterial
sheath a 5 French pigtail catheter was advanced into the mid
abdominal aorta and digital subtraction angiography was
performed. The pigtail catheter was removed and exchanged for a
4 French RIM catheter. This catheter was manipulated until it was
in the celiac axis and DSA was performed in frontal projection.
The catheter was then manipulated into the superior mesenteric
artery and a 4F glide cath was then used to advance into the
distal SMA. Proximal and distal SMA DSA was performed in frontal
projection with a portal venous phase injection. The catheter and
sheath were then removed and manual compression was applied until
hemostasis was achieved. A sterile occlusive dressing was
applied at the site. There were no complications
. Dr. was present
for the entire procedure.
ANGIOGRAPHY:
Right Renal arteriogram
Celiac axis arteriogram
Proximal SMA angiogram
Distal SMA angiogram
FINDINGS:
Right renal arteriogram: Subtraction angiography demonstrated a
patent right renal artery with a small perfusion defect in the
upper pole likely form a non filling Accessory artery.
Celiac Angiogram: Subtraction angiography demonstrated a patent
splenic artery, gastro - duodenal , gastro- epiploic and left
hepatic artery. The splenic vein was not seen as the phase was
early venous phase. The right hepatic artery is known to arise
from the SMA as per the prior CT scan.
Proximal Superior Mesenteric Artery/Hepatic Artery Angiogram:
Contrast single plane subtraction angiography demonstrated a
replaced right hepatic artery just distal to the origin of the
SMA.
The hepatic artery arises from a tortuous origin and feeds a
large right hepatic lobe tumor of moderate vascularity without
evidence of portal venous hepatic venous shunting. The right
hepatic lobe is compressed and faint hepatic vein opacification
is seen.
Distal Superior Mesenteric Artery Angiogram: Contrast single
plane subtraction angiography of the distal SMA demonstrates a
normal SMA and branches. The portovenous phase demonstrated the
main portal vein at the confluence of the SMV and splenic vein
shunting directly to the upper IVC consistent With an Abernathy
type 1 shunt. No intra-hepatic portal vein branches were seen
from this injection.
Permanent US and fluoroscopic images were obtained and stored in
the PACS system.
SHUNT CONTRAST INJECTION VI JUGULAR ACCESS:
LEFT PORTAL VEIN DELINEATION
PROCEDURE: Attention was turned to the the right neck and a
limited US was performed to identify the RIJ vein and choose a
site for insertion of the access needle. The skin overlying the
site was marked. The skin of the right neck ultrasound guidance
a 21 gauge needle was inserted into the right internal jugular
vein. Once venous blood return was obtained a 0.018" mandril
wire was inserted into the vein and advanced to the right atrium.
The small dermatotomy was made, the tract was dilated, and a 4f
vascular sheath was inserted into the right atrium.
VENOGRAPHY:
Right hepatic vein
Shuntogram/cavogram
Splenic vein venography
Left portal vein venography
A JB-1 catheter was advanced into the right hepatic vein and an
angiographic run was performed confirming patentcy of the right
hepatic vein and normal drainage to the RA
The JB-1 was then advanced easily into the upper IVC and shunt
and a splenic vein venogram performed demonstrating a patent
splenic vein and interior mesenteric vein with direct drainage to
the IVC.
The JB-1 was then exchanged for a Cobra Glidecath and after
multiple attempts a vessel draining into the main portal
vein/shunt was cannulated and contrast injected demonstrating the
probable left portal vein with direct left hepatic vein shunting
to the right atrium.
The catheter and sheath were then removed and hemostasis achieved
after 5mins. The child left the IR suite in stable condition.
In view of having used 5.5mls/kg of contrast it ws decided to
reschedule the right hepatic tumor embolization and lower
cavogram for another interval.
IMPRESSION
1. Replaced right hepatic artery off SMA.
2. Large right hepatic lobe tumor with moderate vascularity
supplied by several branches of right hepatic artery without
evidence of shunting.
3. SMA portography Main portal vein draining directly to the IVC
after the splenic and SMV confluence consistent with an Abernathy
malformation type 1. No intra-hepatic portal branches were
identified with arterial portography.
4. Patent left hepatic, splenic and and gastro - duodenal
arteries.
5. Direct contrast injection of shunt via RIJ access demonstrated
patent right hepatic and left hepatic veins.
6. Direct contrast injection of shunt via RIJ access demonstrated
patent splenic vein and IVC shunting directly to the IVC.
7. Direct cannulation of shunt demonstrated a probable left
portal vein with multiple hepatic venous shunts.
Is anyone out there today who can help me with this one?
Possible codes: 36245,75726,36245-59,75726-59,36011-59,36012,36481,75887...what about the shuntogram? Also, didn't see selective catheterization of renal artery...
Exam: IR Angio Visceral Selective
IR Angio Renal Unilateral Completed: 05/08/2014 4:45 PM
05/08/2014 4:45 PM
Indications:
Diagnosis:Hyperbilirubinemia [782.4 (ICD-9-CM)]<br />Liver mass [573.9 (ICD-9-CM)]
Hyperbilirubinemia [782.4 (ICD-9-CM)]<br />Liver mass [573.9 (ICD-9-CM)]
Reason:8yo with large hepatic lesion, arterial embolization to decrease mass size
LIVER MASS
Interpretation:
CLINICAL HISTORY: History of large hepatic tumor, likely adenoma,
for pre operative portal vein and hepatic vein planning and
possible embolization of tumor.
COMPARISON: CTA 4/22/14, MRI 3/21/14
PROCEDURE TIME: 3 hours
WEIGHT: 24kgs
PROCEDURE: The skin of the right groin was prepped and draped in
sterile fashion. Using US guidance a 21 gauge needle was inserted
in the right common femoral artery. Once arterial blood return
was obtained a .018" Mandril wire was placed into the artery and
advanced to the distal abdominal aorta. The needle was removed
and replaced with a 5 French micropuncture sheath/dilator set.
The wire was sized up to a .035" Newton wire, and a 5 French
vascular sheath was placed into the artery. Via the arterial
sheath a 5 French pigtail catheter was advanced into the mid
abdominal aorta and digital subtraction angiography was
performed. The pigtail catheter was removed and exchanged for a
4 French RIM catheter. This catheter was manipulated until it was
in the celiac axis and DSA was performed in frontal projection.
The catheter was then manipulated into the superior mesenteric
artery and a 4F glide cath was then used to advance into the
distal SMA. Proximal and distal SMA DSA was performed in frontal
projection with a portal venous phase injection. The catheter and
sheath were then removed and manual compression was applied until
hemostasis was achieved. A sterile occlusive dressing was
applied at the site. There were no complications
. Dr. was present
for the entire procedure.
ANGIOGRAPHY:
Right Renal arteriogram
Celiac axis arteriogram
Proximal SMA angiogram
Distal SMA angiogram
FINDINGS:
Right renal arteriogram: Subtraction angiography demonstrated a
patent right renal artery with a small perfusion defect in the
upper pole likely form a non filling Accessory artery.
Celiac Angiogram: Subtraction angiography demonstrated a patent
splenic artery, gastro - duodenal , gastro- epiploic and left
hepatic artery. The splenic vein was not seen as the phase was
early venous phase. The right hepatic artery is known to arise
from the SMA as per the prior CT scan.
Proximal Superior Mesenteric Artery/Hepatic Artery Angiogram:
Contrast single plane subtraction angiography demonstrated a
replaced right hepatic artery just distal to the origin of the
SMA.
The hepatic artery arises from a tortuous origin and feeds a
large right hepatic lobe tumor of moderate vascularity without
evidence of portal venous hepatic venous shunting. The right
hepatic lobe is compressed and faint hepatic vein opacification
is seen.
Distal Superior Mesenteric Artery Angiogram: Contrast single
plane subtraction angiography of the distal SMA demonstrates a
normal SMA and branches. The portovenous phase demonstrated the
main portal vein at the confluence of the SMV and splenic vein
shunting directly to the upper IVC consistent With an Abernathy
type 1 shunt. No intra-hepatic portal vein branches were seen
from this injection.
Permanent US and fluoroscopic images were obtained and stored in
the PACS system.
SHUNT CONTRAST INJECTION VI JUGULAR ACCESS:
LEFT PORTAL VEIN DELINEATION
PROCEDURE: Attention was turned to the the right neck and a
limited US was performed to identify the RIJ vein and choose a
site for insertion of the access needle. The skin overlying the
site was marked. The skin of the right neck ultrasound guidance
a 21 gauge needle was inserted into the right internal jugular
vein. Once venous blood return was obtained a 0.018" mandril
wire was inserted into the vein and advanced to the right atrium.
The small dermatotomy was made, the tract was dilated, and a 4f
vascular sheath was inserted into the right atrium.
VENOGRAPHY:
Right hepatic vein
Shuntogram/cavogram
Splenic vein venography
Left portal vein venography
A JB-1 catheter was advanced into the right hepatic vein and an
angiographic run was performed confirming patentcy of the right
hepatic vein and normal drainage to the RA
The JB-1 was then advanced easily into the upper IVC and shunt
and a splenic vein venogram performed demonstrating a patent
splenic vein and interior mesenteric vein with direct drainage to
the IVC.
The JB-1 was then exchanged for a Cobra Glidecath and after
multiple attempts a vessel draining into the main portal
vein/shunt was cannulated and contrast injected demonstrating the
probable left portal vein with direct left hepatic vein shunting
to the right atrium.
The catheter and sheath were then removed and hemostasis achieved
after 5mins. The child left the IR suite in stable condition.
In view of having used 5.5mls/kg of contrast it ws decided to
reschedule the right hepatic tumor embolization and lower
cavogram for another interval.
IMPRESSION
1. Replaced right hepatic artery off SMA.
2. Large right hepatic lobe tumor with moderate vascularity
supplied by several branches of right hepatic artery without
evidence of shunting.
3. SMA portography Main portal vein draining directly to the IVC
after the splenic and SMV confluence consistent with an Abernathy
malformation type 1. No intra-hepatic portal branches were
identified with arterial portography.
4. Patent left hepatic, splenic and and gastro - duodenal
arteries.
5. Direct contrast injection of shunt via RIJ access demonstrated
patent right hepatic and left hepatic veins.
6. Direct contrast injection of shunt via RIJ access demonstrated
patent splenic vein and IVC shunting directly to the IVC.
7. Direct cannulation of shunt demonstrated a probable left
portal vein with multiple hepatic venous shunts.
