Neuro-Endovascular Procedures

jonyleo20

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INTERVENTIONAL NEURORADIOLOGY/ENDOVASCULAR NEUROSURGERY OPERATIVE
NOTE
PREOPERATIVE DIAGNOSES-
VERTEBROBASILAR INSUFFICIENCY
BILATERAL VERTEBRAL ARTERY OCCLUSIONS
S/P RIGHT COMMON CAROTID TO RIGHT VERTEBRAL ARTERY VENOUS BYPASS GRAFT

POSTOPERATIVE DIAGNOSES-
SEVERE GRAFT ANASTOMOTIC STENOSIS WITH FLOW RESTRICTION AND THROMBUS
GRAFT ANASTOMOTIC LEAK
IATROGENIC LEFT VERTEBRAL ARTERY DISSECTION/DISSECTING ANEURYSM
S/P LEFT SUBCLAVIAN SAPTA

PROCEDURES\E\OPERATIONS-
DIAGNOSTIC FOUR VESSEL-VASCULAR FAMILY CATHETER CEREBRAL/CERVICAL DSA
STENT-ASSISTED ANEURYSM OCCLUSION OF LEFT VERTEBRAL ARTERY DISSECTING
ANEURYSM
MECHANICAL THROMBOLYSIS OF GRAFT/DISTAL ANASTOMOSIS
STENT-ASSISTED PERCUTANEOUS ANGIOPLASTY OF RIGHT COMMON CAROTID
BYPASS GRAFT
BALLOON TAMPONADE OF ANASTOMOTIC LEAK

NEURO ENDOVASCULAR SURGEON- JOHN C. CHALOUPKA, MD, FAHA, FACA

ANESTHESIA- GETA^ SEE ANESTHESIA NOTES FOR DETAILS

COMBINED ESTIMATED BLOOD LOSS- 500 ML.

COMPLICATIONS- GRAFT ANASTOMOTIC LEAKAGE AFTER PTA REQUIRING BALLOON
TAMPONADE AND SURGICAL REVISION

INDICATIONS- SEVERELY SYMPTOMATIC VERTEBROBASILAR INSUFFICIENCY
SECONDARY TO BILATERAL VERTEBRAL ARTERY OCCLUSIONS^ S/P LEFT
SUBCLAVIAN ARTERY SAPTA^ S/P RECENT RCCA TO RVA BYPASS^ EVALUATE
PATENCY OF GRAFT.

MATERIALS EMPLOYED-
18G SINGLE WALL PUNCTURE NEEDLE
6FR 11 CM SHEATH,
BENTSON 0.038" GUIDE WIRE,
0.035" TERUMO GUIDE WIRE,
5FR ANGLED GLIDE DIAGNOSTIC CATHETER,
6FR 90-CM ENVOY MPD,
4.5-MM X 37-MM ENTERPRISE STENT, AND
4.5 X 15 MILLIMETER WINGSPAN STENT,
3.5 MM X 9 MM GATEWAY PTA BALLOON MICROCATHETER
4 MM X 9 MM GATEWAY PTA MICHAEL BALLOON CATHETER
014 300-CM PT GRAPHIX EXCHANGE CORONARY WIRE
0.027" PROWLER SELECT PLUS MICROCATHETER
VESSELS INJECTED-
RIGHT COMMON CAROTID ARTERY,
RIGHT SUBCLAVIAN ARTERY,
RIGHT VERTEBRAL ARTERY,
RIGHT DEEP CERVICAL ARTERY,
THE PROCEDURE, ITS RISKS (INCLUDING STROKE, DEATH, BLEEDING, COMA,
DAMAGE TO BLOOD VESSELS, INFECTION, AND ADVERSE REACTION TO
MEDICATIONS), BENEFITS, AND ALTERNATIVES WERE DISCUSSED WITH THE
PATIENT AND HIS FAMILY (WIFE AND SONS). ALL QUESTIONS WERE ANSWERED
AND INFORMED CONSENT WAS OBTAINED. THE PATIENT WAS BROUGHT INTO THE
NEURO-INTERVENTIONAL SUITE AND PLACED ON THE FLUORO/DSA TABLE IN A
SUPINE POSITION. A PROCEDURAL TIMEOUT WAS TAKEN TO VERIFY THE CORRECT
PATIENT AND INTERVENTION. THE RIGHT GROIN WAS PREPPED AND DRAPED IN
THE USUAL STERILE FASHION. THE RIGHT COMMON FEMORAL ARTERY WAS
ACCESSED VIA A MODIFICATION OF THE SELDINGER TECHNIQUE USING SINGLE
PUNCTURE TECHNIQUE WITH AN #18G SINGLE-WALL NEEDLE. INITIALLY A #5
FRENCH 23 CM TERUMO SHEATH WAS COAXIALLY PLACED OVER A GUIDEWIRE
THROUGH THE RIGHT CFA ARTERIOTOMY AND CONNECTED TO A PRESSURIZED
CONTINUOUS HEPARINIZED NORMAL INFUSION
THE 5-FRENCH ANGLED GLIDE DIAGNOSTIC CATHETER WAS SERIALLY ADVANCED
OVER A 0.035" TERUMO GLIDEWIRE INTO THE ASCENDING AORTA, AND THEN
MANIPULATED SERIALLY INTO THE GREAT VESSELS UNDER UNSUBTRACTED
FLUOROSCOPIC GUIDANCE FOR SELECTIVE CATHETERIZATION DSA AS FOLLOWS-
THE RIGHT COMMON CAROTID ARTERY WAS SELECTIVELY CATHETERIZED. BIPLANE
CERVICAL CAROTID ANGIOGRAPHY WAS PERFORMED. MULTIPLANAR CEREBRAL
CAROTID ANGIOGRAPHY WAS THEN PERFORMED.
THE RIGHT SUBCLAVIAN ARTERY WAS SELECTIVELY CATHETERIZED. BIPLANE
UPPER THORACIC AND CERVICAL DSA WAS PERFORMED.
THE RIGHT VERTEBRAL ARTERY WAS SELECTIVELY CATHETERIZED. BIPLANAR
CEREBRAL ANGIOGRAPHY WAS PERFORMED.
RIGHT DEEP CERVICAL ARTERY WAS SELECTIVELY CATHETERIZED. BIPLANE
UPPER THORACIC AND CERVICAL DSA WAS PERFORMED.

FINDINGS-
RIGHT COMMON CAROTID ARTERY CERVICAL ANGIOGRAM-
POSTOPERATIVE CHANGES SEEN WITHIN THE MID CERVICAL PORTION OF THE
RIGHT COMMON CAROTID ARTERY CONSISTING OF AN ECCENTRIC CURVILINEAR
ENDOLUMINAL FILLING DEFECT ALONG THE MEDIAL WALL OF THE RIGHT COMMON
CAROTID ARTERY WITH A SMALL AREA OF CENTRAL FOCAL OUTPOUCHING
PROJECTING MEDIALLY. THIS DEFECT IS SEEN IN THE VICINITY OF SMALL
SURGICAL CLIPS AND IS LIKELY THE SITE OF ANASTOMOSIS BETWEEN RIGHT
COMMON CAROTID ARTERY AND RIGHT VERTEBRAL ARTERY. THERE IS NO FLOW
SEEN WITHIN THE ORIGINAL GRAFT.
A NEW BYPASS GRAFT IS SEEN JUST DISTAL TO THE ORIGINAL SITE
CONSISTING OF AN END TO SIDE ANASTOMOSIS OF INTERPOSED SAPHENOUS VEIN
WHICH THEN TRAVELS INFERIORLY AND POSTERIORLY TO AN END TO END
ANASTOMOSIS WITH THE MOBILIZED LOWER CERVICAL RIGHT VERTEBRAL ARTERY.
THERE IS EVIDENCE OF THROMBUS FORMATION JUST PROXIMAL TO THE DISTAL
ANASTOMOTIC SITE WITH THE VERTEBRAL ARTERY. FURTHERMORE, AT THE
DISTAL ANASTOMOTIC SITE WITH THE VERTEBRAL ARTERY, THERE IS A SEVERE
ANASTOMOTIC STENOSIS MEASURING OVER 95%. THERE IS ASSOCIATED FLOW
RESTRICTION. THERE IS AN IATROGENIC DISSECTION OF THE PROXIMAL
CERVICAL LEFT VERTEBRAL ARTERY RESULTING IN A DISSECTING ANEURYSM
WITH FLOW WITHIN THE FALSE LUMEN. A PROMINENT FLAP IS SEEN AS WELL.
ADDITIONALLY, THERE IS INTERMITTENT EXTRAVASATION SEEN WITHIN THE
DISTAL VENOUS GRAFT, WHICH APPEARS TO POTENTIALLY BE ARISING FROM A
SMALL TRIBUTARY BRANCH ATTACHED TO THE VEIN. THERE IS A MILD AMOUNT
OF EXTRAVASATION NOTED INTERMITTENTLY.
THE RIGHT CAROTID ARTERY TREE SHOWS MILD-MODERATE ATHEROSCLEROTIC
DISEASE AFFECTING THE COMMON CAROTID BIFURCATION AND INTERNAL CAROTID
ARTERY BULB. THERE IS EFFACEMENT OF THE RIGHT INTERNAL CAROTID ARTERY
BULB. THERE IS A PROMINENT SIGMOIDAL CERVICAL LOOP WITH A HORIZONTAL
KINK-LIKE STENOSIS RESULTING IN APPROXIMATELY 50% NARROWING.
DOLICHOECTASIA. THE VISUALIZED PORTIONS OF THE EXTERNAL CAROTID
ARTERY AND ITS BRANCHES ARE OF NORMAL COURSE AND CALIBER. PATHOLOGIC
COLLATERALS WITHIN THE RIGHT SUBOCCIPITAL CARREFOUR VIA RIGHT
OCCIPITAL ARTERY ARE AGAIN NOTED TO BE RECONSTITUTING THE DISTAL
CERVICAL PORTION OF THE RIGHT VERTEBRAL ARTERY.
THE INTRACRANIAL PORTIONS OF THE RIGHT INTERNAL ARTERY SHOW NORMAL
CALIBER AND COURSE. THERE IS A NARROW NECK, APPROXIMATELY 4-MM
SPHERICAL ANEURYSM ARISING FROM THE ANTICIPATED ORIGIN OF THE RIGHT
POSTERIOR COMMUNICATING ARTERY. THERE IS NORMAL CAROTID TERMINAL
BIFURCATION INTO RIGHT A1 ACA AND RIGHT M1 MCA BRANCHES. THE RIGHT M1
SEGMENT IS ALSO NORMAL IN CALIBER AND COURSE. DISTAL MCA AND ACA
TERRITORIES SHOW NORMAL DISTRIBUTION AND COURSE. THERE IS NORMAL
TRANSIT TIME. THERE IS SPONTANEOUS CROSS FILLING INTO THE LEFT ACA
TERRITORY FROM A PATENT ANTERIOR COMMUNICATING ARTERY. THERE IS NO
EVIDENCE OF ADDITIONAL ANEURYSMS, ARTERIOVENOUS AUTOMATION, OR
ARTERIOVENOUS SHUNTING.
RIGHT SUBCLAVIAN ARTERY ANGIOGRAM- THE RIGHT SUBCLAVIAN ARTERY SHOWS
MILD DOLICHOECTASIA AND SCATTERED ATHEROSCLEROTIC PLAQUE,
PARTICULARLY IN THE PROXIMAL SEGMENT IN WHICH THERE IS AN ECCENTRIC
CALCIFICATION. HOWEVER, NO HEMODYNAMICALLY SIGNIFICANT STENOSES ARE
IDENTIFIED. THERE IS COMPLETE 100% OCCLUSION AT THE ORIGIN OF THE
RIGHT VERTEBRAL ARTERY. THERE IS NOW MINIMAL COLLATERAL FILLING OF
THE CERVICAL PORTION OF THE RIGHT VERTEBRAL ARTERY FROM MUSCULAR
COLLATERALS ARISING FROM THE DEEP CERVICAL ARTERY. THE MAJOR
BRANCHES ARISING FROM THE SUBCLAVIAN ARTERY ARE PROMINENT, OWING TO
COLLATERAL RECRUITMENT.
RIGHT DEEP CERVICAL ARTERY DSA- IS NOTABLE FOR GIVING RISE TO DISTAL
AND MID CERVICAL MUSCULAR BRANCHES THAT HAVE BEEN THE PREDOMINANT
COLLATERAL SUPPLY FOR RECONSTITUTION THE CERVICAL RIGHT VERTEBRAL
ARTERY. HOWEVER THESE COLLATERALS ARE LESS PROMINENT THAN PREVIOUSLY
NOTED OWING TO THE NEWLY CONSTRUCTED RCCA TO RVA BYPASS GRAFT.
(MULTIPLANAR VIEWS)- SELECTION OF THE RIGHT VERTEBRAL ARTERY VIA THE
BYPASS GRAFT IS NOTABLE FOR A 2.5 CENTIMETER LENGTH OF DISSECTING
ANEURYSM WITH FALSE LUMEN NOTED ALONG THE MEDIAL ASPECT OF THE
VESSEL. THE RIGHT VERTEBRAL ARTERY IS DOMINANT WITH A UNIFORMLY
LARGE DIAMETER MEASURING AT LEAST 5 MM. THERE IS MILD
ATHEROSCLEROTIC DISEASE SEEN WITHIN THE LOWER AND MID CERVICAL
SEGMENTS WITHOUT HEMODYNAMICALLY SIGNIFICANT STENOSIS. VERTEBRAL
ARTERY JOINS THE VERTEBRAL BASILAR JUNCTION WITH NORMAL VISUALIZATION
OF THE VERTEBRAL BASILAR CIRCULATION AS DESCRIBED IN PREVIOUS
STUDIES. NO THROMBOEMBOLIC PHENOMENA ARE NOTED.
ENDOVASCULAR OPERATIONS-
FOR THE ENDOVASCULAR SURGICAL PORTIONS OF THE PROCEDURE, THE
INDWELLING RIGHT COMMON FEMORAL ARTERY SHEATH WAS EXCHANGED FOR A
6-FRENCH 23 CM TERUMO SHEATH POSITIONED IN THE LOWER ABDOMINAL AORTA.
THROUGH THE SHEATH A NUMBER 6-FRENCH 90-CM MPD GUIDING CATHETER WAS
POSITIONED WITHIN THE RIGHT COMMON CORONARY AND CAREFULLY MANIPULATED
AT THE ORIGIN OF THE PROXIMAL ANASTOMOSIS BETWEEN RIGHT COMMON
CAROTID ARTERY AND RIGHT VERTEBRAL ARTERY. THROUGH THE GUIDING
CATHETER MULTIPLE INTERVENTIONS WERE PERFORMED AS FOLLOWS-
NEURO-ENDOVASCULAR OPERATION #1- MECHANICAL THROMBOLYSIS OF
GRAFT/DISTAL ANASTOMOSIS
A PROWLER PLUS SELECT MICROCATHETER AND SYNCHRO-2 014 MICROGUIDEWIRE
COMBINATION WAS MANIPULATED INTO THE BYPASS GRAFT AND NAVIGATED TO
THE PROXIMAL EXTENT OF THE GRAFT THROMBUS. MECHANICAL THROMBOLYSIS
WAS THEN PERFORMED USING BOTH THE MICROGUIDEWIRE AND MICROCATHETER.
DURING THIS TIME CONTINUOUS SUCTION ASPIRATION OF THE PROXIMAL GRAFT
WAS PERFORMED THROUGH THE GUIDING CATHETER POSITIONED WITHIN THE
PROXIMAL ANASTOMOSIS. CONTROL DSA FROM COMMON CAROTID INJECTION
SHOWED COMPLETE REMOVAL OF THE THROMBUS. THERE REMAINS A SEVERE
RESIDUAL DISTAL ANASTOMOTIC STENOSIS MEASURING OVER 95%.
NEURO-ENDOVASCULAR OPERATION #2- STENT-ASSISTED ANEURYSM OCCLUSION
THE PROWLER PLUS MICROGUIDEWIRE COMBINATION WAS THEN NAVIGATED ACROSS
THE SEVERE STENOSIS INTO THE PROXIMAL CERVICAL RIGHT VERTEBRAL
ARTERY. SUPERSELECTED TEST INJECTION THROUGH THE MICROCATHETER AGAIN
NOTED THE PSEUDOANEURYSM FORMATION DESCRIBED ABOVE. UNDER CONTINUOUS
FLUOROSCOPIC GUIDANCE AND DIGITAL ROADMAP FLUOROSCOPY, THE
MICROCATHETER WAS CAREFULLY NAVIGATED THROUGH THE TRUE LUMEN AND PAST
THE AREA OF THE DISSECTING ANEURYSM INTO AND ANGIOGRAPHICALLY NORMAL
SEGMENT OF THE CERVICAL RIGHT VERTEBRAL ARTERY. MEASUREMENTS WERE
MADE TO DETERMINE THE OPTIMAL LENGTH OF STENT NECESSARY TO TREAT THE
PSEUDOANEURYSM. A 4.5 MM X 37 MM ENTERPRISE STENT WAS THEN LOADED
INTO THE MICROCATHETER AND PUSHED INTO POSITION ACROSS THE DISSECTING
ANEURYSM. CAREFUL AND SLOW UNSHEATHING UNDER DIGITAL ROADMAP WAS
THEN PERFORMED PERMITTING DEPLOYMENT OF THE STENT ACROSS THE ENTIRE
EXTENT OF THE DISSECTING ANEURYSM. CONTROL ANGIOGRAPHY IMMEDIATELY
UPON DEPLOYMENT OF THE STENT SHOWED NEARLY COMPLETE OCCLUSION OF THE
FALSE CHANNEL WITH SUBSTANTIALLY REDUCED FILLING OF THE
PSEUDOANEURYSM. INTERMITTENT EXTRAVASATION ARISING FROM THE SAME
POINT WITHIN THE SEPTUM IS GRAFT WAS NOTED.
NEURO-ENDOVASCULAR OPERATION #3- STENT-ASSISTED PERCUTANEOUS
ANGIOPLASTY OF RIGHT COMMON CAROTID BYPASS GRAFT
THE DISTAL ANASTOMOTIC STENOSIS WAS RECROSSED WITH THE PROWLER PLUS
SELECT MICROCATHETER AND SYNCHRO SOFT MICROGUIDEWIRE IN WHICH DISTAL
PURCHASE WAS OBTAINED WITHIN THE MID CERVICAL VERTEBRAL ARTERY PAST
THE STENTED DISSECTING ANEURYSM SEGMENT. IT 300-CM PT GRAPHIX
EXCHANGE WIRE WAS THEN PLACED INTO POSITION, ALLOWING REMOVAL OF THE
MICROCATHETER. OVER THE EXCHANGE WIRE, A 4.5 MILLIMETER X 15-MM
WINGSPAN SELF EXPANDING STENT DELIVERY SYSTEM WAS NAVIGATED ACROSS
THE STENOSIS IN WHICH THE STENT DISTAL AND PROXIMAL MARKER BANDS WERE
POSITIONED EQUI-DISTANCE FROM THE STENOSIS. UNDER CONTINUOUS
FLUOROSCOPIC GUIDANCE AND DIGITAL ROADMAP FLUOROSCOPY, THE STENT WAS
SLOWLY DEPLOYED USING UNSHEATHING TECHNIQUE. THE STENT DEPLOYED
FULLY ACROSS THE TARGETED STENOSIS WITH GOOD APPROXIMATION SEEN
DISTALLY AND PROXIMALLY FROM GRAFT TO PROXIMAL CERVICAL VERTEBRAL
ARTERY. THERE WAS IMMEDIATELY IMPROVED RESTORATION OF LUMINAL
DIAMETER AT THE ANASTOMOSIS SECONDARY TO POSITIVE REMODELING FORCE OF
THE SELF-EXPANDING STENT. HOWEVER, CONTROL DSA AFTER DEPLOYMENT
SHOWED SIGNIFICANT RESIDUAL ANASTOMOTIC STENOSIS WHICH REQUIRED POST
DILATATION. CONSEQUENTLY, A 4-MM X 9-MM GATEWAY PTA BALLOON CATHETER
WAS NAVIGATED THROUGH THE WINGSPAN STENT INTO THE ANASTOMOTIC
STENOSIS. PROPER POSITIONING WAS CONFIRMED ON DIGITAL SUBTRACTION
ANGIOGRAPHY AND ROADMAP FLUOROSCOPY. UNDER CONTINUOUS FLUOROSCOPIC
GUIDANCE, THE BALLOON WAS SLOWLY INFLATED TO SUBNORMAL PRESSURES IN
WHICH ABATEMENT OF WASTING WAS NOTED. THREE CYCLES OF BALLOON
INFLATION/DEFLATION WERE PERFORMED. FINAL CONTROL DSA AFTER PTA
SHOWED SIGNIFICANTLY IMPROVED RESTORATION OF LUMINAL DIMENSION OF THE
ANASTOMOSIS. THERE WAS STILL RESIDUAL STENOSIS MEASURING
APPROXIMATELY 25 TO 30%. THERE WAS ALSO CONTINUED EVIDENCE OF
EXTRAVASATION SEEN AT THE ORIGINAL PREINTERVENTION SITE OF THE GRAFT,
AS WELL AS AT THE AREA OF RECENTLY DILATED ANASTOMOSIS. THE DEGREE OF
EXTRAVASATION HAS INCREASED SINCE THE BEGINNING OF THE CASE. THIS
PROMPTED ADDITIONAL INTERVENTION IS DESCRIBED BELOW.
NEURO-ENDOVASCULAR OPERATION #4- BALLOON TAMPONADE OF ANASTOMOTIC LEAK
INITIALLY, THE 4-MM X 9-MM GATEWAY PTA BALLOON MICROCATHETER WAS
REPOSITIONED ACROSS THE AREAS OF VISUALIZED EXTRAVASATION AND THEN
INFLATED TO SUBNORMAL PRESSURES UNTIL FLOW REST WAS ACHIEVED.
BALLOON TAMPONADE WAS PERFORMED INTERMITTENTLY OVER PERIODS OF 2-5
MINUTES AT A TIME. SEVERAL INTERVAL ANGIOGRAMS WERE PERFORMED AFTER
DEFLATION OF THE BALLOON IN WHICH THERE WAS TRANSIENT REDUCTION OF
EXTRAVASATION. HOWEVER, DELAYED CONTROL RUNS SHOWED CONTINUED
BLEEDING WHICH WAS ESSENTIALLY CHANGED FROM THE RATE OF EXTRAVASATION
SEEN BEFORE IMPLEMENTING BALLOON TAMPONADE. CONSEQUENTLY, A LARGER
PTA BALLOON WAS SELECTED CONSISTING OF A 4.5-MM X 9-MM GATEWAY PTA
BALLOON MICROCATHETER. AGAIN, THE MICROCATHETER WAS REPOSITIONED
ACROSS THE AREAS ARE VISUALIZED EXTRAVASATION AND THEN CYCLICALLY
INFLATED TO SUBNORMAL PRESSURES UNTIL FLOW ARREST WAS ACHIEVED.
OCCLUSION TIMES FROM 5 TO 10 MINUTES WERE UTILIZED CYCLICALLY.
UNFORTUNATELY, AGAIN ALTHOUGH INITIAL SUBSTANTIAL REDUCTION OF
EXTRAVASATION WAS SEEN UPON IMMEDIATE DEFLATION OF THE BALLOON,
REPEAT CONTROL DSA SHOWED RETURNED BLEEDING TO PREINTERVENTION
LEVELS. MULTIPLE INFLATION CYCLES WERE MADE OVER A PERIOD OF
APPROXIMATELY 40 MINUTES. AT THIS JUNCTURE IN COLLABORATION WITH
DR.SAVINA AND DR. KANTROWITZ KANTROWITZ, IT WAS ELECTED TO REEXPLORE
THE ANASTOMOSIS TO IDENTIFY THE SOURCE OF BLEEDING AND CORRECT IT
WITH AN OPEN SURGICAL PROCEDURE.
ENDOVASCULAR OPERATION #5- RIGHT COMMON ILIAC ANGIOGRAPHY &
PERCUTANEOUS ARTERIOTOMY CLOSURE
COMPLICATIONS- NONE.
INDICATIONS- PROLONGED ARTERIAL SHEATH PLACEMENT WITH NEED FOR
INTERMITTENT ANTICOAGULATION.
MATERIALS EMPLOYED- 6FR, 11 CM SHEATH, BENTSON 0.038" GUIDE WIRE,
ANGIO-SEAL 6-FRENCH KIT
VESSELS INJECTED- AORTO-ILIAC BIFURCATION\S\ LEFT COMMON ILIAC
ARTERY PROCEDURE- CONTROL DSA THROUGH AORTO-ILIAC AND RIGHT COMMON
ILIAC ARTERY INJECTION WERE PERFORMED.
FINDINGS- MILD BILATERAL ILIAC BIFURCATION ATHEROSCLEROTIC DISEASE
WITHOUT STENOSIS OR OCCLUSION. NORMAL TRANSIT TIME. NORMAL BILATERAL
COMMON ILIAC ARTERIES WITHOUT EVIDENCE OF STENOSIS. RIGHT COMMON
ILIAC ARTERY INJECTION SHOWS NORMAL CALIBER AND COURSE OF THE RIGHT
COMMON ILIAC ARTERY THE RIGHT COMMON ILIAC BIFURCATION, RIGHT
INTERNAL AND EXTERNAL ILIAC ARTERIES. THERE IS NO EVIDENCE OF
INTRALUMINAL THROMBUS OR DISTRACTION. THERE IS NORMAL RAPID RUNOFF.
NO INTIMAL INJURY IS SEEN IN THE LEFT COMMON FEMORAL ARTERIOTOMY. THE
ARTERIOTOMY IS BELOW THE INGUINAL LIGAMENT AND ABOVE THE RIGHT COMMON
FEMORAL ARTERY BIFURCATION. THE ARTERIAL ACCESS SHEATH WAS THEN
EXCHANGED OVER A WIRE FOR THE ACCESS SHEATH USED WITH THE 6-FRENCH
ANGIO-SEAL KIT. PROPER POSITIONING OF THE SHEATH WAS CONFIRMED
THROUGH PULSATILE BLOOD FLOW IN WHICH WIRE AND DILATOR WERE REMOVED
AND EXCHANGED FOR THE ANGIO-SEAL PLUGS. THE PLUGS WERE PLACED IN
STANDARD FASHION IN WHICH GOOD HEMOSTASIS WAS ACHIEVED. RIGHT COMMON
FEMORAL ARTERY WAS STILL EASILY PALPATED. FULL HEMOSTASIS WAS
ACHIEVED.
FINAL IMPRESSIONS/SUMMARY-
1. PATENT 2ND BYPASS GRAFT JUST DISTAL TO THE ORIGINAL SITE
CONSISTING OF END TO SIDE ANASTOMOSIS OF INTERPOSED SAPHENOUS VEIN
WHICH THEN TRAVELS INFERIORLY AND POSTERIORLY TO AN END TO END
ANASTOMOSIS WITH THE MOBILIZED LOWER CERVICAL RIGHT VERTEBRAL ARTERY.
THROMBUS FORMATION JUST PROXIMAL TO THE DISTAL ANASTOMOTIC SITE WITH
THE VERTEBRAL ARTERY. DISTAL ANASTOMOTIC SITE HAS A SEVERE
ANASTOMOTIC STENOSIS MEASURING OVER 95%. INTERMITTENT EXTRAVASATION
ARISING FROM DISTAL VENOUS GRAFT, WHICH APPEARS TO ARISE FROM A SMALL
TRIBUTARY BRANCH ATTACHED TO THE VEIN.
2. OCCLUDED 1ST RCCA TO R VA VENOUS BYPASS GRAFT RIGHT
3. IATROGENIC DISSECTION/DISSECTING ANEURYSM OF PROXIMAL CERVICAL
RIGHT VERTEBRAL ARTERY
4. TECHNICALLY SUCCESSFUL STENT-ASSISTED ANEURYSM OCCLUSION OF
DISSECTING ANEURYSM OF PROXIMAL CERVICAL RIGHT VERTEBRAL ARTERY
5. TECHNICALLY SUCCESSFUL MECHANICAL THROMBOLYSIS OF GRAFT/DISTAL
ANASTOMOSIS
6. TECHNICALLY SUCCESSFUL STENT-ASSISTED PERCUTANEOUS ANGIOPLASTY OF
RIGHT COMMON CAROTID BYPASS GRAFT
7. TECHNICALLY UNSUCCESSFUL BALLOON TAMPONADE OF ANASTOMOTIC LEAKS
8. TECHNICALLY SUCCESSFUL PERCUTANEOUS ARTERIOTOMY CLOSURE WITH 6 FR
ANGIOSEAL DEVICE

HELP PLS !!!!!!!!!!!!!!!!!!!!!!1 :eek::confused::confused:
 

dpeoples

True Blue
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That will give you a big headache.

without really dissecting this, I am thinking
0075t for the Vert stent
0076T for the CC stent.
These codes include all cath placements and diagnostic images.

HTH :)
 

donnajrichmond

True Blue
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Well the first thing I would do is talk to whomever is in charge of your reporting system and make them change from all CAPS to sentence case - this was really hard to read!

There was also mechanical thrombectomy in there, so 36174. And I'm not sure about the balloon tamponade - that took a long time and was separate from the stenting - possibly 37799.
Danny, Jim - what do y'all think?
 
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