Question PLEASE HELP - Percutaneous mechanical thrombectomy & Arterial thrombolysis, subsequent treatment day, cessation of treatment and catheter removal

Best answers
1. Arterial thrombolysis, subsequent treatment day, cessation of treatment and catheter removal
2. Percutaneous mechanical thrombectomy left ATA, CIA, EIA ? 37184, 37185 OR 37214 ?
3. PTA / stent left CIA and EIA 37221 LT 37223 LT
4. Radiologic supervision and interpretation of all of the above

Brief history and indication for procedure: Pt with acute limb ischemia, suspected acute on chronic ischemia with thrombosis of LE arteries and chronic PAD. S/P arteriogram and intra-arterial thrombolysis with infusion catheter left for overnight infusion of TPA. Decision made to return to OR POD 1 for F/U imaging and indicated procedures. I have discussed risks, benefits and alternatives with the patient and family and have answered all questions.  They are in agreement with proceeding with this plan.

Description of procedure and findings: Pt in OR in supine position. Mild sedation administered. Both groins prepped. Existing sheath and catheter in right groin prepped into operative field and patient draped in sterile fashion. Initial arteriogram performed through infusion catheter.

ANGIOGRAPHIC FINDINGS: Popliteal artery is widely patent and completely clear of thrombus. PTA is widely patent and clear of thrombus and continuous onto the foot. The peroneal artery is small with moderate disease but no focal HDS stenosis and no thrombus. The ATA is occluded 2 cm distal to its origin with reconstitution a couple of cm distal to the occlusion. The ATA is then continuous to the foot. Occlusion appears thrombotic.

The sheath was then withdrawn into the proximal CIA and proximal LLE arteriogram was performed.

ANGIOGRAPHIC FINDINGS: The CIA and EIA have recannalized. There is flow through the entire CIA and EIA. There is a distal CIA aneurysm. There is a high-grade stenosis of the CIA just distal to the aneurysm. There is a moderate stenosis of the distal EIA. There is residual thrombus in the CIA and EIA.

Pt systemically heparinized. 6 Fr sheath exchanged for 7 Fr sheath. Angiojet Solent Proxi catheter advanced over the wire into the proximal CIA. Percutaneous pharmacologic and mechanical thrombectomy of the CIA and EIA performed with the angiojet in power pulse using 6 mg of TPA. Attention then turned to the tibial arteries while the TPA was allowed to work.

An 0.014 Choice PT wire was advanced through the sheath. With the aid of a vertebral catheter, the SFA was selected and subsequent third order selection of the ATA was performed. The angiojet was advanced into the ATA and percutaneous mechanical thrombectomy of the ATA was performed in power pulse with suction mode. F/U angiography was performed.

ANGIOGRAPHIC FINDINGS: Following percutaneous angiojet mechanical thrombectomy, the ATA is clear of thrombus and widely patent onto the foot with no stenosis and no residual thrombus. No complicating findings.

Proximal LLE arteriogram was then repeated through the sheath.

ANGIOGRAPHIC FINDINGS: Following mechanical thrombectomy, the CIA and EIA are clear of thrombus. Stenoses as described above.

Decision made to treat both the aneurysm and the stenosis in the CIA with covered stent. An 8 mm x 5 cm Viabahn stent was deployed across both the aneurysm and the stenosis and post-dilated with an 8 mm angioplasty balloon. F/U arteriogram showed excellent results with no residual stenosis and no complicating factors. Aneurysm completely excluded.

A 6 mm Lutonix drug-coated balloon was then deployed across the distal EIA stenosis. 3-minute balloon inflation was performed. F/U angiography showed resolution of the stenosis but there was a focal dissection at the area of angioplasty. Dissection was then treated with a 6 mm bare metal self-expanding stent. F/U angiography showed excellent results with no residual stenosis and no complicating findings. Completion run-off arteriogram performed.

ANGIOGRAPHIC FINDINGS: Excellent in-line arterial flow throughout the LLE with no complications.

Protamine administered. Sheath exchanged for standard length sheath. Contrast injection through sheath showed no access site complications. Sheath irrigated and access closed with exoseal closure device. Sheath removed and pressure held for 5 minutes per protocol. Very small non-expanding hematoma, no bleeding. Sterile dressing applied. Pt transported to recovery in stable condition. Palpable DP and PT pulse at completion.


Best answers
This case would actual be coded as follows.
37221-LT, 37223-LT, 37184, 37185, 36247-XS-LT, 75710-XU-LT

CIA Stenting- 37221-LT
EIA Stent- 37223-
CIA Mechanical Thrombectomy-37184
EIA- Mechanical Thrombectomy- 37185.
3rd Order ATA cath placement-36247-XS
Angiography, Lower ext, Unilateral RS&I-75710-XU.

Mechanical Thrombectomy includes Thrombolysis when both are performed in same vessel same encounter we code for the Thrombectomy. Documentation clearly supports s mechanical Thrombectomy and in no way, shape or form support 37214. Even if it did if 37214 and 37184 both done same vessel code 37184 .

CIA-37184 EIA, ATA 37185.
37185 covers the second Thrombectomy and all additional vessels in the SAME extremity.
Since the Anterior Tibial Artery is part of the tibial/Peroneal vasculature and a 3rd Order selection was performed catheterization is reported separately from mechanical thrombectomy.
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