margaret fahy
Guru
10/30/13
Hi, Guys,
Would someone be so kind as to check my codes on this one.
Thank you so very much.
I have 36147, 36215, 75710, 36870. I didn't code for the attempted piece of wire removal..what do you think...and 36215? Is this correct?...and no post angio run code for these?
Margie
CLINICAL HISTORY: 8-year-old male patient with history of
end-stage renal disease, here for declotting of left arm AV
PROCEDURE:
1. Access of the AV graft in 2 sites; venous and arterial
directions, under ultrasound guidance.
2. Central venogram.
3. Arterial anastomosis angiogram
4. Mechanical maceration of the graft clots utilizing Trerotola
device.
5. Post mechanical clots maceration graftogram.
PROCEDURE IN DETAIL:
The patient was placed supine on the angiographic table and the
left arm was prepped and draped in a sterile fashion. Limited
ultrasound examination demonstrated obstructive thrombosis
within the graft. The venous limb of the graft was accessed
using a micropuncture needle. A 0.018 guidewire was passed and
after a series of exchanges, a 7 French vascular sheath was
placed within the graft. Next a 0.021" Nitrex guidewire was
passes centrally, and a 4 French KMP catheter passed. Contrast
was injected and central venogram was obtained which
demonstrated complete occlusion of the left brachiocephalic vein
with multiple prominent collaterals including the transverse
jugular vein. Then a second 7 French vascular sheath was placed
directed towards the arterial limb of the graft. A 4 French KMP
catheter was advanced over the wire into the arterial
anastomosis. The contrast was injected and arterial anastomoses
angiogram was obtained which demonstrated patent anastomosis
without evidence of stenoses. Then mechanical maceration of the
graft using Trerotola device was performed. At the end the
arterial anastomosis plug was removed utilizing 5 French Fogarty
balloon. At this time of the procedure the Nitrex wire found to
be migrated distally through the abdominal aorta and the tip was
stuck into a small branch of the left internal iliac artery. A
few attempts were performed to extract the wire but were
unsuccessful.
The wire was pulled and during the process, it was noted that
the wire came out, however the tip of the wire (which is thin
wire wound around the core) got unravelled and the thin wire was
seen from the branch of the left internal iliac artery all the
way upto the graft.
Additional access at the distal most aspect of the graft was
obtained and a 7 French sheath was placed. Utilizing multiple
snare catheters and bronchoscopic biopsy forceps, the wire was
pulled from the new vascular sheath. Then a 5 mm snare catheter
was advanced over the wire into the distal most reachable
portion of the wire. The wire was pulled from the sheath leaving
a small fragment of the tip within a small posterior branch of
the left internal iliac artery. The decision was made to leave
this fragment of the wire within the non-critical arterial
branch.
Additional session of mechanical maceration was performed within
the arterial and venous limbs of the graft. Then the contrast
was injected which demonstrated almost complete opacification of
the graft with improvement of flow the graft. There were small
filling defects compatible with clots seen along the tip of the
sheath. There was no stenosis at the arterial or venous
anastomoses. A good pulse and palpable thrill was felt.
FINDINGS:
1. Complete occlusion of the left brachiocephalic vein with
multiple collaterals.
2. Thrombosis of left AV graft.
3. Mechanical maceration of AV graft thrombosis utilizing
Trerotola device.
Complication: A small unwound filament fragment of the tip of
0.021" Nitrex wire was stuck in a small posterior branch of the
left internal iliac artery as described above.
The sheaths were removed and hemostasis achieved using
purse-string sutures and manual pressure. A sterile dressing was
applied and the patient was transferred from IR suite in stable
condition.
IMPRESSION
1. Complete occlusion of the left brachiocephalic vein with
multiple collaterals.
2. Successful mechanical maceration of the AV graft thrombosis
utilizing Trerotola device with improvement of flow through the
graft and palpable thrill overall the graft.
3. Retained foreign body - a small unwound filament fragment of
the tip of 0.021" Nitrex wire was stuck in a small posterior
branch of the left internal iliac artery as described above.
Hi, Guys,
Would someone be so kind as to check my codes on this one.
Thank you so very much.
I have 36147, 36215, 75710, 36870. I didn't code for the attempted piece of wire removal..what do you think...and 36215? Is this correct?...and no post angio run code for these?
Margie
CLINICAL HISTORY: 8-year-old male patient with history of
end-stage renal disease, here for declotting of left arm AV
PROCEDURE:
1. Access of the AV graft in 2 sites; venous and arterial
directions, under ultrasound guidance.
2. Central venogram.
3. Arterial anastomosis angiogram
4. Mechanical maceration of the graft clots utilizing Trerotola
device.
5. Post mechanical clots maceration graftogram.
PROCEDURE IN DETAIL:
The patient was placed supine on the angiographic table and the
left arm was prepped and draped in a sterile fashion. Limited
ultrasound examination demonstrated obstructive thrombosis
within the graft. The venous limb of the graft was accessed
using a micropuncture needle. A 0.018 guidewire was passed and
after a series of exchanges, a 7 French vascular sheath was
placed within the graft. Next a 0.021" Nitrex guidewire was
passes centrally, and a 4 French KMP catheter passed. Contrast
was injected and central venogram was obtained which
demonstrated complete occlusion of the left brachiocephalic vein
with multiple prominent collaterals including the transverse
jugular vein. Then a second 7 French vascular sheath was placed
directed towards the arterial limb of the graft. A 4 French KMP
catheter was advanced over the wire into the arterial
anastomosis. The contrast was injected and arterial anastomoses
angiogram was obtained which demonstrated patent anastomosis
without evidence of stenoses. Then mechanical maceration of the
graft using Trerotola device was performed. At the end the
arterial anastomosis plug was removed utilizing 5 French Fogarty
balloon. At this time of the procedure the Nitrex wire found to
be migrated distally through the abdominal aorta and the tip was
stuck into a small branch of the left internal iliac artery. A
few attempts were performed to extract the wire but were
unsuccessful.
The wire was pulled and during the process, it was noted that
the wire came out, however the tip of the wire (which is thin
wire wound around the core) got unravelled and the thin wire was
seen from the branch of the left internal iliac artery all the
way upto the graft.
Additional access at the distal most aspect of the graft was
obtained and a 7 French sheath was placed. Utilizing multiple
snare catheters and bronchoscopic biopsy forceps, the wire was
pulled from the new vascular sheath. Then a 5 mm snare catheter
was advanced over the wire into the distal most reachable
portion of the wire. The wire was pulled from the sheath leaving
a small fragment of the tip within a small posterior branch of
the left internal iliac artery. The decision was made to leave
this fragment of the wire within the non-critical arterial
branch.
Additional session of mechanical maceration was performed within
the arterial and venous limbs of the graft. Then the contrast
was injected which demonstrated almost complete opacification of
the graft with improvement of flow the graft. There were small
filling defects compatible with clots seen along the tip of the
sheath. There was no stenosis at the arterial or venous
anastomoses. A good pulse and palpable thrill was felt.
FINDINGS:
1. Complete occlusion of the left brachiocephalic vein with
multiple collaterals.
2. Thrombosis of left AV graft.
3. Mechanical maceration of AV graft thrombosis utilizing
Trerotola device.
Complication: A small unwound filament fragment of the tip of
0.021" Nitrex wire was stuck in a small posterior branch of the
left internal iliac artery as described above.
The sheaths were removed and hemostasis achieved using
purse-string sutures and manual pressure. A sterile dressing was
applied and the patient was transferred from IR suite in stable
condition.
IMPRESSION
1. Complete occlusion of the left brachiocephalic vein with
multiple collaterals.
2. Successful mechanical maceration of the AV graft thrombosis
utilizing Trerotola device with improvement of flow through the
graft and palpable thrill overall the graft.
3. Retained foreign body - a small unwound filament fragment of
the tip of 0.021" Nitrex wire was stuck in a small posterior
branch of the left internal iliac artery as described above.
