jamiebangs
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Need help with this surgery coding
Preoperative Diagnosis:
1. Traumatic injury, car accident
2. Vertebral artery dissection bilateral
3. Left internal carotid artery dissection
Postoperative diagnosis:
1. Same
Operation:
Diagnostic cerebral angiogram (vessel selection, angiography, and radiographic interpretation)
Vertebral artery left and right
Internal carotid artery right
External carotid artery right
Internal carotid artery left
External carotid artery left
Thyrocervical trunk right
Thyrocervical trunk left
Costal cervical trunk left
ultrasound guided vascular access
General Anesthesia
Findings:
Bilateral vertebral artery dissections, complete occlusions
Left internal carotid artery dissections, persistent flow, greater than 70% stenosis, no thrombus
Complications:
none immediate or anticipated
Disposition:
To ICU in hemodynamically stable condition, dopamine infusion
Indications for procedure:
patient with carotid artery dissection and vertebral artery dissections seen on noninvasive imaging. Concern for brain hypoperfusion. Patient is intubated in critical condition secondary to her traumatic brain injury and polytrauma. In order maximize diagnostic sensitivity, digital subtraction angiography is indicated. The patient was brought to the catheterization lab emergently
Detailed description of procedure:
The patient was placed on the angiography table. Cardiac monitors were placed. General endotracheal anesthesia was induced. The right hand and wrist were prepped and draped in the standard sterile fashion. All pressure points were carefully padded. A universal timeout was performed in accordance with hospital policy.
The right distal radial artery was evaluated as a potential access site using ultrasound. It was found to be patent and of suitable size. The right radial artery was accessed with ultrasound guidance using a 21 g needle in real-time. I noted that the wire had a hard time getting past the elbow. I took an x-ray. I saw that there was a compound type fracture of the humerus on the right side. I suspected that there was also possible vascular injury as why the wire would not pass. Therefore I abandoned further attempts at radial access. Her extremity was warm and well-perfused. Radial pulse was normal after the wire was removed
I then proceeded to left common femoral access. Micro puncture kit was used. Access was gained using ultrasound real-time visualization in the common femoral segment. Wire pass freely. Seven French short sheath was then exchanged for the micro puncture kit without difficulty. Angiography of the common femoral artery demonstrated good entry, no evidence of dissection, no thrombus, suitable for closure device.
I then brought up a angle tapered glide cath for diagnostic angiography.
A permanent image was recorded and stored. A stainless steel wire was passed into the radial artery freely. The wire position was confirmed with ultrasound and fluoroscopy. I then introduced a short 5F Glidesheath slender sheath over the wire. 200 mcg of nitroglycerin, 5mg of verapamil, and 5000 U of heparin were infused into the sheath to prevent spasm and radial artery occlusion. A floppy versicore wire was then advanced through a glidecath into the right subclavian artery using roadmap guidance. The Glidecath was then formed in the descending aorta.
The right vertebral artery was selected off of the subclavian artery using roadmap guidance. Angiography was then performed of the cervical and intracranial circulation. The vertebral artery was occluded a few centimeters past its origin. There was no evidence of distal reconstitution.
Next the right thyrocervical trunk was selected off of the subclavian artery using roadmap guidance. Angiography was then performed of the cervical and intracranial circulation. There was normal filling of the thyrocervical trunk and its branches. There was no evidence of anastomosis with the vertebral artery proximally or distally.
The right internal carotid artery was selected. The right middle cerebral artery and anterior cerebral artery filled briskly. Also the bilateral anterior cerebral arteries filled and the basilar artery filled through the PCOM and I could even see some filling of the vertebral arteries proximal to the vertebrobasilar junction. There was no delay in transit There were no aneurysms identified. The capillary and venous phases were nominal.
The right external carotid artery was selected. There was normal filling of the extra cranial circulation without evidence for extra cranial to intracranial anastomosis or fistula.
The left vertebral artery was selected off of the subclavian artery using roadmap guidance. Angiography was then performed of the cervical and intracranial circulation. There was complete occlusion of the vertebral artery a few centimeters past its origin. There was no distal reconstitution.
The left internal carotid artery was selected. The left middle cerebral artery and posterior communicating artery filled briskly. There was filling of the basilar artery as well. There was an extensive arterial dissection in the cervical region. I estimated that there was about 70% stenosis resulting from the dissection flap. However there was no associated thrombus. There was also good filling of the intracranial circulation without any delay in transit. There were no aneurysms identified. The capillary and venous phases were nominal.
The left external carotid artery was selected. There was normal filling of the extra cranial circulation without evidence for extra cranial to intracranial anastomosis or fistula.
The left thyrocervical trunk was selected. There was normal filling of the arterial tree. No evidence for fistula to the brain or upper cervical spine or intracranial anastomosis.
The left costocervical trunk was selected. There was normal filling of the arterial tree. No evidence for fistula to the brain or upper cervical spine or intracranial anastomosis.
Preoperative Diagnosis:
1. Traumatic injury, car accident
2. Vertebral artery dissection bilateral
3. Left internal carotid artery dissection
Postoperative diagnosis:
1. Same
Operation:
Diagnostic cerebral angiogram (vessel selection, angiography, and radiographic interpretation)
Vertebral artery left and right
Internal carotid artery right
External carotid artery right
Internal carotid artery left
External carotid artery left
Thyrocervical trunk right
Thyrocervical trunk left
Costal cervical trunk left
ultrasound guided vascular access
General Anesthesia
Findings:
Bilateral vertebral artery dissections, complete occlusions
Left internal carotid artery dissections, persistent flow, greater than 70% stenosis, no thrombus
Complications:
none immediate or anticipated
Disposition:
To ICU in hemodynamically stable condition, dopamine infusion
Indications for procedure:
patient with carotid artery dissection and vertebral artery dissections seen on noninvasive imaging. Concern for brain hypoperfusion. Patient is intubated in critical condition secondary to her traumatic brain injury and polytrauma. In order maximize diagnostic sensitivity, digital subtraction angiography is indicated. The patient was brought to the catheterization lab emergently
Detailed description of procedure:
The patient was placed on the angiography table. Cardiac monitors were placed. General endotracheal anesthesia was induced. The right hand and wrist were prepped and draped in the standard sterile fashion. All pressure points were carefully padded. A universal timeout was performed in accordance with hospital policy.
The right distal radial artery was evaluated as a potential access site using ultrasound. It was found to be patent and of suitable size. The right radial artery was accessed with ultrasound guidance using a 21 g needle in real-time. I noted that the wire had a hard time getting past the elbow. I took an x-ray. I saw that there was a compound type fracture of the humerus on the right side. I suspected that there was also possible vascular injury as why the wire would not pass. Therefore I abandoned further attempts at radial access. Her extremity was warm and well-perfused. Radial pulse was normal after the wire was removed
I then proceeded to left common femoral access. Micro puncture kit was used. Access was gained using ultrasound real-time visualization in the common femoral segment. Wire pass freely. Seven French short sheath was then exchanged for the micro puncture kit without difficulty. Angiography of the common femoral artery demonstrated good entry, no evidence of dissection, no thrombus, suitable for closure device.
I then brought up a angle tapered glide cath for diagnostic angiography.
A permanent image was recorded and stored. A stainless steel wire was passed into the radial artery freely. The wire position was confirmed with ultrasound and fluoroscopy. I then introduced a short 5F Glidesheath slender sheath over the wire. 200 mcg of nitroglycerin, 5mg of verapamil, and 5000 U of heparin were infused into the sheath to prevent spasm and radial artery occlusion. A floppy versicore wire was then advanced through a glidecath into the right subclavian artery using roadmap guidance. The Glidecath was then formed in the descending aorta.
The right vertebral artery was selected off of the subclavian artery using roadmap guidance. Angiography was then performed of the cervical and intracranial circulation. The vertebral artery was occluded a few centimeters past its origin. There was no evidence of distal reconstitution.
Next the right thyrocervical trunk was selected off of the subclavian artery using roadmap guidance. Angiography was then performed of the cervical and intracranial circulation. There was normal filling of the thyrocervical trunk and its branches. There was no evidence of anastomosis with the vertebral artery proximally or distally.
The right internal carotid artery was selected. The right middle cerebral artery and anterior cerebral artery filled briskly. Also the bilateral anterior cerebral arteries filled and the basilar artery filled through the PCOM and I could even see some filling of the vertebral arteries proximal to the vertebrobasilar junction. There was no delay in transit There were no aneurysms identified. The capillary and venous phases were nominal.
The right external carotid artery was selected. There was normal filling of the extra cranial circulation without evidence for extra cranial to intracranial anastomosis or fistula.
The left vertebral artery was selected off of the subclavian artery using roadmap guidance. Angiography was then performed of the cervical and intracranial circulation. There was complete occlusion of the vertebral artery a few centimeters past its origin. There was no distal reconstitution.
The left internal carotid artery was selected. The left middle cerebral artery and posterior communicating artery filled briskly. There was filling of the basilar artery as well. There was an extensive arterial dissection in the cervical region. I estimated that there was about 70% stenosis resulting from the dissection flap. However there was no associated thrombus. There was also good filling of the intracranial circulation without any delay in transit. There were no aneurysms identified. The capillary and venous phases were nominal.
The left external carotid artery was selected. There was normal filling of the extra cranial circulation without evidence for extra cranial to intracranial anastomosis or fistula.
The left thyrocervical trunk was selected. There was normal filling of the arterial tree. No evidence for fistula to the brain or upper cervical spine or intracranial anastomosis.
The left costocervical trunk was selected. There was normal filling of the arterial tree. No evidence for fistula to the brain or upper cervical spine or intracranial anastomosis.