LE thrombectomy, stent, and angioplasty

such78

Expert
Messages
327
Location
Baldwin Park, CA
Best answers
0
1.Left external iliac stent occlusion.
2.History of infrarenal aortic aneurysm and left common iliac aneurysm.
3.Left lower extremity claudication.

NAME OF PROCEDURES:
1.Ultrasound-guided access of left common femoral artery.
2.Aortogram with the iliac runoff.
3.Percutaneous arterial thrombectomy of left external iliac artery and stent
using Penumbra Lightning 7 and Penumbra 12 systems.
4.Angioplasty with relining of left exernal iliac artery stent using a Viabahn 13
mm x 10 cm stent.
5.ProGlide closure of left common femoral artery access site.

INDICATION FOR PROCEDURE:
This is a 73-year-old male who had a
history of infrarenal AAA along with left common iliac aneurysm.
Patient underwent endovascular repair of the AAA along with his iliac
aneurysm.However, patient reports that approximately 3 or 4 days
after the procedure, he started suddenly having left low back and leg pain.
Patient was evaluated in clinic and then subsequently underwent a CT scan.Patient was found to have occlusion of the left external iliac
stent limb.As a result of the imaging finding and patient's
symptoms, patient is taken back to the angio suite today for
operative intervention.

SUMMARY OF PROCEDURE: After informed consent was obtained, patient
was brought back to the angio suite and placed on the table in supine
position.Thereafter, patient was placed under general anesthesia.
Next, his bilateral groins were prepped and draped in the usual sterile fashion.
Time-out was performed to indicate correct patient, procedure, site.

We first used the ultrasound and micropuncture kit to assist us in gaining
access to the left common femoral artery.Once we gained
access with a micropuncture needle, we then subsequently advanced our
micropuncture wire to the iliac artery and into the external iliac
stent.Next, we placed our micropuncture sheath.

Subsequently, we then exchanged our wire for a 0.035 Nitrex wire and
advanced an 8-French sheath over the Nitrex wire.After that was
done, we then proceeded to shoot a diagnostic angio of the
iliofemoral complex.

We saw that the patient had thrombosis of the left external iliac artery, extending
to the external iliac artery stent.Hence, we decided to perform
thrombectomy using the Penumbra system.We first used the Lightning
7 system to perform our thrombectomy.After multiple passes using
the thrombectomy device, we saw that we were able to relieve a
significant amount of the thrombus, however there was still some remnant
thrombus that could be seen.

Next we proceeded to exchange for a 12-French sheath.Through the 12-French
sheath, we then proceeded to use the Penumbra 12 system.We used the Penumbra
12 system to remove the remnant thrombus and our post-treatment angiogram
confirmed further improvement.

After we were done with our thrombectomy, we then proceeded to examine the
left external iliac stent, which we noted to be compressed at the proximal to mid portion.
We were able to advance a Bentson wire with assistance of a 4-French
Glidecath and passed the wire up into the infrarenal aorta.A omniflush catheter was
advanced over the wire.We shot an angiogram with runoff into the iliac limbs.We
could appreciate again that the external iliac limb was in fact compressed via our
angiographic study.Due to these findings, we decided to reline our external iliac stent
for additional radial force.

We used a 13 mm x 10 cm Viabahn stent and placed the proximal extent of the stent just
cephalad to the proximal extent of the hypogastric stent.After the stent was deployed, we then proceeded to perform angioplasty of the stent using
an EverCross 12 x 40mm balloon.

We shot a completion aortogram and we were able to see that there was much better flow characteristics
through the external iliac artery stent, and we then performed a completion left lower extremity angiogram
and saw that there was no distal emboli and the patient still had a good flow
distally to the foot with the anterior tibial artery being the main
provider for the flow to the foot.Satisfied with the results, we
then proceeded to remove our catheter and sheath.We had
previously preloaded 2 ProGlide closure devices at our left common
femoral artery access site and we use those ProGlide devices to
close our arteriotomy site.The patient had good hemostasis at the
end of the case.Manual pressure was applied for 5 minutes and then
afterwards we dressed our skin incision site using Dermabond.At the
end of the case, the patient had a palpable left dorsalis pedis pulse.He was awakened in
the angio suite and taken to the recovery room in stable conditions.

Am I correct to assign 37221 -LT and 37186 for this case?

please advice. Thank you/
 

mk2001

Guru
Messages
128
Best answers
0
1.Left external iliac stent occlusion.
2.History of infrarenal aortic aneurysm and left common iliac aneurysm.
3.Left lower extremity claudication.

NAME OF PROCEDURES:
1.Ultrasound-guided access of left common femoral artery.
2.Aortogram with the iliac runoff.
3.Percutaneous arterial thrombectomy of left external iliac artery and stent
using Penumbra Lightning 7 and Penumbra 12 systems.
4.Angioplasty with relining of left exernal iliac artery stent using a Viabahn 13
mm x 10 cm stent.
5.ProGlide closure of left common femoral artery access site.

INDICATION FOR PROCEDURE:
This is a 73-year-old male who had a
history of infrarenal AAA along with left common iliac aneurysm.
Patient underwent endovascular repair of the AAA along with his iliac
aneurysm.However, patient reports that approximately 3 or 4 days
after the procedure, he started suddenly having left low back and leg pain.
Patient was evaluated in clinic and then subsequently underwent a CT scan.Patient was found to have occlusion of the left external iliac
stent limb.As a result of the imaging finding and patient's
symptoms, patient is taken back to the angio suite today for
operative intervention.

SUMMARY OF PROCEDURE: After informed consent was obtained, patient
was brought back to the angio suite and placed on the table in supine
position.Thereafter, patient was placed under general anesthesia.
Next, his bilateral groins were prepped and draped in the usual sterile fashion.
Time-out was performed to indicate correct patient, procedure, site.

We first used the ultrasound and micropuncture kit to assist us in gaining
access to the left common femoral artery.Once we gained
access with a micropuncture needle, we then subsequently advanced our
micropuncture wire to the iliac artery and into the external iliac
stent.Next, we placed our micropuncture sheath.

Subsequently, we then exchanged our wire for a 0.035 Nitrex wire and
advanced an 8-French sheath over the Nitrex wire.After that was
done, we then proceeded to shoot a diagnostic angio of the
iliofemoral complex.

We saw that the patient had thrombosis of the left external iliac artery, extending
to the external iliac artery stent.Hence, we decided to perform
thrombectomy using the Penumbra system.We first used the Lightning
7 system to perform our thrombectomy.After multiple passes using
the thrombectomy device, we saw that we were able to relieve a
significant amount of the thrombus, however there was still some remnant
thrombus that could be seen.

Next we proceeded to exchange for a 12-French sheath.Through the 12-French
sheath, we then proceeded to use the Penumbra 12 system.We used the Penumbra
12 system to remove the remnant thrombus and our post-treatment angiogram
confirmed further improvement.

After we were done with our thrombectomy, we then proceeded to examine the
left external iliac stent, which we noted to be compressed at the proximal to mid portion.
We were able to advance a Bentson wire with assistance of a 4-French
Glidecath and passed the wire up into the infrarenal aorta.A omniflush catheter was
advanced over the wire.We shot an angiogram with runoff into the iliac limbs.We
could appreciate again that the external iliac limb was in fact compressed via our
angiographic study.Due to these findings, we decided to reline our external iliac stent
for additional radial force.

We used a 13 mm x 10 cm Viabahn stent and placed the proximal extent of the stent just
cephalad to the proximal extent of the hypogastric stent.After the stent was deployed, we then proceeded to perform angioplasty of the stent using
an EverCross 12 x 40mm balloon.

We shot a completion aortogram and we were able to see that there was much better flow characteristics
through the external iliac artery stent, and we then performed a completion left lower extremity angiogram
and saw that there was no distal emboli and the patient still had a good flow
distally to the foot with the anterior tibial artery being the main
provider for the flow to the foot.Satisfied with the results, we
then proceeded to remove our catheter and sheath.We had
previously preloaded 2 ProGlide closure devices at our left common
femoral artery access site and we use those ProGlide devices to
close our arteriotomy site.The patient had good hemostasis at the
end of the case.Manual pressure was applied for 5 minutes and then
afterwards we dressed our skin incision site using Dermabond.At the
end of the case, the patient had a palpable left dorsalis pedis pulse.He was awakened in
the angio suite and taken to the recovery room in stable conditions.

Am I correct to assign 37221 -LT and 37186 for this case?

please advice. Thank you/
Would it be 37184 and 37221? Because of the statements, "After we were done with our thrombectomy, we then proceeded to examine the left external iliac stent, which we noted to be compressed at the proximal to mid portion. and Due to these findings, we decided to reline our external iliac stent for additional radial force.", I was thinking the thrombectomy was the original planned procedure so it would be a primary thrombectomy instead of a secondary.
 

such78

Expert
Messages
327
Location
Baldwin Park, CA
Best answers
0
Would it be 37184 and 37221? Because of the statements, "After we were done with our thrombectomy, we then proceeded to examine the left external iliac stent, which we noted to be compressed at the proximal to mid portion. and Due to these findings, we decided to reline our external iliac stent for additional radial force.", I was thinking the thrombectomy was the original planned procedure so it would be a primary thrombectomy instead of a secondary.
that is what I thought at the 1st place, but when I read this "subsequently, we then exchanged our wire for a 0.035 Nitrex wire and advanced an 8-French sheath over the Nitrex wire.After that was done, we then proceeded to shoot a diagnostic angio of the iliofemoral complex. We saw that the patient had thrombosis of the left external iliac artery, extending to the external iliac artery stent." It sounds the original plan was for in-stent stenosis of external iliac. They found thrombus after aniogram during procedure. Pre-OP dx is not indicated thrombus/clot, so it made me thinking to assign 37186 instead of 37184.
 
Last edited:

Jim Pawloski

True Blue
Messages
1,517
Location
Ann Arbor
Best answers
2
When a stent is placed first and a clot breaks off and goes down stream and possible occlusion occurs. Then the doctor chases after the clot and removes it, that is when you use 37186.
 

such78

Expert
Messages
327
Location
Baldwin Park, CA
Best answers
0
When a stent is placed first and a clot breaks off and goes down stream and possible occlusion occurs. Then the doctor chases after the clot and removes it, that is when you use 37186.
Hello Jim.

This IR was planned for stent replacement, and surgeon discovered thrombus during stenting, so it had to be removed before stent placed. So 37186 should be reported instead of 37184. Because 37186 can be reported prior/after other IR procedures for the same encounter, when the planned procedure was not thrombectomy.
 
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