Anug123
Networker
Hi,
Anyone suggest the codes for the documentation..
1. THORACIC ABDOMINAL AND PELVIC ARTERIOGRAMS.
2. FENESTRATION:OF ACUTE TYPE-B AORTIC DISSECTION.
3. MODERATE SEDATION.
CLINICAL HISTORY:
THIS IS A 59-YEAR-OLD FEMALE WHO PRESENTED TO AN OUTSIDE HOSPITAL WITH
ACUTE ONSET OF BACK PAIN. INITIAL WORK UP DEMONSTRATED THE PRESENCE OF
ACUTE TYPE-B AORTIC DISSECTION. WHILE IN THE EMERGENCY ROOM AT THE OUTSI
FACILITY, THE PATIENT BECAME PARALYZED IN BOTH LOWER EXTREMITIES.
AT THAT TIME, I RECEIVED A CALL FROM THE ER PHYSICIAN AND THE PATIENT WA
TRANSFERRED TO BAPTIST HOSPITAL FOR FURTHER EVALUATION AND POSSIBLE
TREATMENT.
CONSENT:
PRIOR TO THE PROCEDURE, THE PROCEDURE, RISKS, BENEFITS AND ALTERNATIVES
WERE DISCUSSED WITH THE PATIENT AND HER FRIENDS PRESENT IN THE EMERGENCY
ROOM. ATTEMPT WAS: MADE TO CONTACT NEXT OF KIN, BUT THIS WAS UNSUCCESSFUL.
PROCEDURE:
THE PATIENT WAS PLACED SUPINE ON THE ANGIOGRAPHY TABLE AND BOTH GROINS W RE
PREPPED AND DRAPED IN A STANDARD STERILE FASHION.
AFTER ADMINISTERING LOCAL ANESTHESIA, AN 18-GAUGE SINGLE-WALL NEEDLE WAS
UTILIZED TO PUNCTURE THE RIGHT COMMON FEMORAL VEIN. A 0.035 BENTSON WIRE
WAS ADVANCED THROUGH THE NEEDLE CENTRALLY AND THE NEEDLE WAS REMOVED.
ACCESS WAS SECURED WITH A 5-FRENCH VASCULAR SHEATH. A 4-FRENCH PIGTAIL
CATHETER WAS ADVANCED OVER THE WIRE AND THE WIRE AND CATHETER WERE ADVAN ED
ACROSS THE ARCH TO THE ASCENDING AORTA. THE WIRE WAS REMOVED AND A FLUSH
THORACIC AORTOGRAN WAS PERFORMED IN THE RAO PROJECTION.
ATTENTION WAS THEN DIRECTED TOWARDS THE LEFT GROIN. AFTER ADMINISTERING
LOCAL ANESTHESIA, AN 18-GAUGE SINGLE-WALL NEEDLE WAS UTILIZED TO PUNCTUR
THE LEFT COMMON FEMORAL ARTERY. A 0.035 WIRE WAS ADVANCED THROUGH THE
NEEDLE CENTRALLY AND ACCESS WAS SECURED WITH A 5-FRENCH VASCULAR SHEATH. A
5-FRENCH MPA CATHETER WAS ADVANCED OVER THE WIRE TO THE LEVEL OF THE CON ION
ILIAC ARTERY, AND THE WIRE WAS REMOVED. CONTRAST INJECTION WAS PERFORMED
THROUGH THE CATHETER TO DETERMINE WHICH LUMEN THE CATHETER WAS IN.
THE PIGTAIL CATHETER WAS RETRACTED TO JUST BELOW THE LEVEL OF THE DIAPHR .GM
AND A FLUSH AORTOGRAM WAS PERFORMED THROUGH THE CATHETER.
THE MPA CATHETER WAS ADVANCED OVER THE BENTSON WIRE AND ADVANCED ACROSS
LARGE HOLE IN THE INTIMAL FLAP, JUST BELOW THE LEVEL OF THE DIAPHRAGM.
MULTIPLE INJECTIONS WERE PERFORMED AT VARIOUS STATIONS TO BETTER DEFINE HE
ANATOMY AND PHYSIOLOGY OF THIS ACUTE DISSECTION.
A 0.035 TORQUE WIRE WAS ADVANCED THROUGH THE MPA CATHETER AND THE CATHET R
WAS REMOVED. ACCESS WAS SECURED IN THE LEFT GROIN WITH A LONG 6-FRENCH
VASCULAR SHEATH. THE SHEATH WAS ADVANCED TO THE LEVEL OF THE SUPRARENAL
AORTA, AND A 5-FRENCH MPA CATHETER WAS READVANCED OVER THE TORQUE WIRE. HE
TORQUE WIRE WAS REMOVED AND A 0.035 WIRE WAS ADVANCED THROUGH THE MPA
CATHETER AND DIRECTED DOWNWARD IN THE FALSE LUMEN OF THIS DISSECTION.
THE WIRE WAS THEN ADVANCED FROM THE LEFT GROIN INFERIORLY IN THE FALSE LUMEN OF THE DISSECTION TO THE LEVEL OF THE COMMON ILIAC ARTERY.
THROUGH THE RIGHT COMMON FEMORAL SHEATH, WHICH WAS POSITIONED IN THE TRU
LUMEN, RE-ENTRY INTO THE FALSE LUMEN WAS ACHIEVED USING A COMBINATION OF
ANGIOGRAPHIC TECHNIQUES, ULTIMATELY WITH A STIFF ANGLED GLIDEWIRE. A 5-
FRENCH CATHETER WAS ADVANCED OVER THE WIRE INTO THE FALSE LUMEN FROM THE
RIGHT GROIN, AND THE WIRE WAS REMOVED. A SMALL LOOP SNARE WAS ADVANCED
THROUGH THE CATHEThR AND USED TO CAPTURE THE WIRE COURSING FROM THE LEFT
GROIN SUPERIORLY INTO THE FALSE LUMEN AND ULTIMATELY INTO THE RIGHT ILIA
ARTERY. THE WIRE WAS THEN PULLED THROUGH THE RIGHT GROIN SHEATH. HOLDING UP
BOTH ENDS OF THE WIRE, THE WIRE WAS PULLED DOWN IN ATTEMPT TO INCREASE T E
SIZE OF THE PRESUMABLY NATURAL FENESTRATION DOWN TO THE LEVEL OF THE AOR IC
BIFURCATION.
ANGIOGRAPHIC RUNS WERE THEN PERFORMED THROUGH THE LEFT GROIN SHEATH. AN
MM ANGIOPLASTY BALLOON WAS ADVANCED OVER THE WIRE AND USED TO
ANGIOPLASTY/DILATE THE ENTRY SITE WE HAD CREATED. THE BALLOON WAS REMOVE:
AND COMPLETION ANGIOGRAPHIC RUNS WERE PERFORMED THROUGH THE LEFT GROIN
SHEATH. THE LEFT GROIN SHEATH WAS REMOVED, AND HEMOSTASIS WAS OBTAINED B
MANUAL COMPRESSION. THE RIGHT GROIN SHEATH WAS LEFT IN PLACE TO FUNCTION AS
AN ARTERIAL LINE,AS THE PATIENT REMAINED CRITICALLY ILL AND WITH GUARDE
PROGNOSIS.
THE PATIENT TOLERATED THE PROCEDURE WELL WITHOUT IMMEDIATE COMPLICATION.
DISCUSSION:
THORACIC AORTA:
FLUSH AORTOGRAM DEMONSTRATES MINIMAL ANEURYSMAL DILATION OF THE ASCENDIN
AORTA. THE SINOTUBULAR JUNCTION IS PRESERVED. THERE IS NORMAL ORIGIN OF HE
BRACHIOCEPHALIC VESSELS. NO SIGNIFICANT STENOSIS IS IDENTIFIED. IMMEDIAT LY
DISTAL TO THE LEFT SUBCLAVIAN VEIN, THERE IS IRREGULARITY OF THE AORTA A D
NARROWING OF THE TRUE LUMEN. THIS PERSISTS TO THE LEVEL OF THE DIAPHRAGM
ABDOMINAL AORTOGRAM:
FLUSH AORTOGRAM PERFORMED FROM THE TRUE LUMEN DEMONSTRATES A LARGE NATUR L
FENESTRATION JUST ABOVE THE LEVEL OF THE RENAL ARTERIES. THERE IS BRISK
FILLING OF THE FALSE LUMEN, BUT NO APPRECIABLE OUTFLOW IS DEMONSTRATED I
THE CHEST OR ABDOMEN.
AFTER EVALUATING THESE FINDINGS AND CONSIDERING THE LIKELIHOOD OF BENEFI
FROM MULTIPLE APPROACHES, AS WELL AS THE RISK OF POTENTIAL COMPLICATIONS
IT WAS DECIDED THE PATIENT WOULD NOT BENEFIT FROM THORACIC FENESTRATION;
HOWEVER, IT WAS FELT THAT THE PATIENT MAY BENEFIT FROM INCREASING THE
OUTFLOW OF THIS FALSE LUMEN AND HOPEFULLY PREVENT ANY PROXIMAL MIGRATION OR
EXTENSION OF THE FALSE LUMEN.
A WIRE WAS PASSED: FROM THE LEFT GROIN ACCESS SITE INTO THE FALSE LUMEN D WN
TO THE MOST INFERIOR ASPECT OF THE FALSE LUMEN WHICH WAS LOCATED IN THE
DISTAL COMMON ILIAC ARTERY.
FROM THE RIGHT GROIN ACCESS SITE, WHICH WAS IN THE TRUE LUMEN, AN ACCESS
WAS MADE INTO THE FALSE LUMEN IN THE REGION OF THE COMMON ILIAC ARTERY. £HE
WIRE FROM THE LEFT GROIN WAS THEN CAPTURED AND PULLED THROUGH THE RIGHT
GROIN ACCESS SHEATH. USING THE “CHEESE GRATER TECHNIQUE”, THE WIRE WAS
PULLED TO INCREASE THE SIZE OF THE FENESTRATION IN THE ABDOMINAL AORTA.
AFTER DOING THIS, FLOW-LIMITING NARROWING WAS PRESENT IN THE ORIGIN OF T
RIGHT COMMON ILIAC ARTERY, AND AN 8 MM ANGIOPLASTY BALLOON WAS THEN
ADVANCED OVER THE. WIRE AND INFLATED ACROSS THIS REGION. THIS SIGNIFICANT
IMPROVED THE FLOW: TO THE RIGHT LEG.
IMPRESSION:
1. FINDINGS CONSISTENT WITH PATIENT'S KNOWN HISTORY OF ACUTE TYPE-B
DISSECTION WITH A NATURAL FENESTRATION IN THE ABDOMINAL AORTA JUST
ABOVE THE LEVEL OF THE RENAL ARTERIES. THIS DISSECTION DOES EXTEND
PROXIMALLY TO THE. LEVEL JUST DISTAL TO THE ORIGIN OF THE LEFT
SUBCLAVIAN ARTERY. THERE IS NO EVIDENCE OF FENESTRATION IN THE CHEST.
FURTHERMORE, FLOW. IN THE THORACIC PORTION OF THIS DISSECTION IS VERY
SLUGGISH; THERE IS A LARGE AMOUNT OF THROMBUS WITHIN THE FALSE LUMEN
IN THE TRANSVERSE ARCH AND THE DISTAL ASPECTS OF THE TRANSVERSE ARCH
AND PROXIMAL DESCENDING AORTA.
2. AFTER EXTENDING THE FENESTRATION THROUGH THE ABDOMINAL AORTA AND
PRESERVING FLOW TO THE RIGHT COMMON ILIAC ARTERY, ANGIOGRAPHIC RUNS
DEMONSTRATE PRESERVED FLOW TO BOTH LOWER EXTREMITIES.
3. THE INTENT OF CREATING/EXTENDING THIS FENESTRATION INFERIORLY WAS T)
HOPEFULLY PREVENT: ANY FURTHER PROXIMAL EXTENSION OF THIS DISSECTION.
Anyone suggest the codes for the documentation..
1. THORACIC ABDOMINAL AND PELVIC ARTERIOGRAMS.
2. FENESTRATION:OF ACUTE TYPE-B AORTIC DISSECTION.
3. MODERATE SEDATION.
CLINICAL HISTORY:
THIS IS A 59-YEAR-OLD FEMALE WHO PRESENTED TO AN OUTSIDE HOSPITAL WITH
ACUTE ONSET OF BACK PAIN. INITIAL WORK UP DEMONSTRATED THE PRESENCE OF
ACUTE TYPE-B AORTIC DISSECTION. WHILE IN THE EMERGENCY ROOM AT THE OUTSI
FACILITY, THE PATIENT BECAME PARALYZED IN BOTH LOWER EXTREMITIES.
AT THAT TIME, I RECEIVED A CALL FROM THE ER PHYSICIAN AND THE PATIENT WA
TRANSFERRED TO BAPTIST HOSPITAL FOR FURTHER EVALUATION AND POSSIBLE
TREATMENT.
CONSENT:
PRIOR TO THE PROCEDURE, THE PROCEDURE, RISKS, BENEFITS AND ALTERNATIVES
WERE DISCUSSED WITH THE PATIENT AND HER FRIENDS PRESENT IN THE EMERGENCY
ROOM. ATTEMPT WAS: MADE TO CONTACT NEXT OF KIN, BUT THIS WAS UNSUCCESSFUL.
PROCEDURE:
THE PATIENT WAS PLACED SUPINE ON THE ANGIOGRAPHY TABLE AND BOTH GROINS W RE
PREPPED AND DRAPED IN A STANDARD STERILE FASHION.
AFTER ADMINISTERING LOCAL ANESTHESIA, AN 18-GAUGE SINGLE-WALL NEEDLE WAS
UTILIZED TO PUNCTURE THE RIGHT COMMON FEMORAL VEIN. A 0.035 BENTSON WIRE
WAS ADVANCED THROUGH THE NEEDLE CENTRALLY AND THE NEEDLE WAS REMOVED.
ACCESS WAS SECURED WITH A 5-FRENCH VASCULAR SHEATH. A 4-FRENCH PIGTAIL
CATHETER WAS ADVANCED OVER THE WIRE AND THE WIRE AND CATHETER WERE ADVAN ED
ACROSS THE ARCH TO THE ASCENDING AORTA. THE WIRE WAS REMOVED AND A FLUSH
THORACIC AORTOGRAN WAS PERFORMED IN THE RAO PROJECTION.
ATTENTION WAS THEN DIRECTED TOWARDS THE LEFT GROIN. AFTER ADMINISTERING
LOCAL ANESTHESIA, AN 18-GAUGE SINGLE-WALL NEEDLE WAS UTILIZED TO PUNCTUR
THE LEFT COMMON FEMORAL ARTERY. A 0.035 WIRE WAS ADVANCED THROUGH THE
NEEDLE CENTRALLY AND ACCESS WAS SECURED WITH A 5-FRENCH VASCULAR SHEATH. A
5-FRENCH MPA CATHETER WAS ADVANCED OVER THE WIRE TO THE LEVEL OF THE CON ION
ILIAC ARTERY, AND THE WIRE WAS REMOVED. CONTRAST INJECTION WAS PERFORMED
THROUGH THE CATHETER TO DETERMINE WHICH LUMEN THE CATHETER WAS IN.
THE PIGTAIL CATHETER WAS RETRACTED TO JUST BELOW THE LEVEL OF THE DIAPHR .GM
AND A FLUSH AORTOGRAM WAS PERFORMED THROUGH THE CATHETER.
THE MPA CATHETER WAS ADVANCED OVER THE BENTSON WIRE AND ADVANCED ACROSS
LARGE HOLE IN THE INTIMAL FLAP, JUST BELOW THE LEVEL OF THE DIAPHRAGM.
MULTIPLE INJECTIONS WERE PERFORMED AT VARIOUS STATIONS TO BETTER DEFINE HE
ANATOMY AND PHYSIOLOGY OF THIS ACUTE DISSECTION.
A 0.035 TORQUE WIRE WAS ADVANCED THROUGH THE MPA CATHETER AND THE CATHET R
WAS REMOVED. ACCESS WAS SECURED IN THE LEFT GROIN WITH A LONG 6-FRENCH
VASCULAR SHEATH. THE SHEATH WAS ADVANCED TO THE LEVEL OF THE SUPRARENAL
AORTA, AND A 5-FRENCH MPA CATHETER WAS READVANCED OVER THE TORQUE WIRE. HE
TORQUE WIRE WAS REMOVED AND A 0.035 WIRE WAS ADVANCED THROUGH THE MPA
CATHETER AND DIRECTED DOWNWARD IN THE FALSE LUMEN OF THIS DISSECTION.
THE WIRE WAS THEN ADVANCED FROM THE LEFT GROIN INFERIORLY IN THE FALSE LUMEN OF THE DISSECTION TO THE LEVEL OF THE COMMON ILIAC ARTERY.
THROUGH THE RIGHT COMMON FEMORAL SHEATH, WHICH WAS POSITIONED IN THE TRU
LUMEN, RE-ENTRY INTO THE FALSE LUMEN WAS ACHIEVED USING A COMBINATION OF
ANGIOGRAPHIC TECHNIQUES, ULTIMATELY WITH A STIFF ANGLED GLIDEWIRE. A 5-
FRENCH CATHETER WAS ADVANCED OVER THE WIRE INTO THE FALSE LUMEN FROM THE
RIGHT GROIN, AND THE WIRE WAS REMOVED. A SMALL LOOP SNARE WAS ADVANCED
THROUGH THE CATHEThR AND USED TO CAPTURE THE WIRE COURSING FROM THE LEFT
GROIN SUPERIORLY INTO THE FALSE LUMEN AND ULTIMATELY INTO THE RIGHT ILIA
ARTERY. THE WIRE WAS THEN PULLED THROUGH THE RIGHT GROIN SHEATH. HOLDING UP
BOTH ENDS OF THE WIRE, THE WIRE WAS PULLED DOWN IN ATTEMPT TO INCREASE T E
SIZE OF THE PRESUMABLY NATURAL FENESTRATION DOWN TO THE LEVEL OF THE AOR IC
BIFURCATION.
ANGIOGRAPHIC RUNS WERE THEN PERFORMED THROUGH THE LEFT GROIN SHEATH. AN
MM ANGIOPLASTY BALLOON WAS ADVANCED OVER THE WIRE AND USED TO
ANGIOPLASTY/DILATE THE ENTRY SITE WE HAD CREATED. THE BALLOON WAS REMOVE:
AND COMPLETION ANGIOGRAPHIC RUNS WERE PERFORMED THROUGH THE LEFT GROIN
SHEATH. THE LEFT GROIN SHEATH WAS REMOVED, AND HEMOSTASIS WAS OBTAINED B
MANUAL COMPRESSION. THE RIGHT GROIN SHEATH WAS LEFT IN PLACE TO FUNCTION AS
AN ARTERIAL LINE,AS THE PATIENT REMAINED CRITICALLY ILL AND WITH GUARDE
PROGNOSIS.
THE PATIENT TOLERATED THE PROCEDURE WELL WITHOUT IMMEDIATE COMPLICATION.
DISCUSSION:
THORACIC AORTA:
FLUSH AORTOGRAM DEMONSTRATES MINIMAL ANEURYSMAL DILATION OF THE ASCENDIN
AORTA. THE SINOTUBULAR JUNCTION IS PRESERVED. THERE IS NORMAL ORIGIN OF HE
BRACHIOCEPHALIC VESSELS. NO SIGNIFICANT STENOSIS IS IDENTIFIED. IMMEDIAT LY
DISTAL TO THE LEFT SUBCLAVIAN VEIN, THERE IS IRREGULARITY OF THE AORTA A D
NARROWING OF THE TRUE LUMEN. THIS PERSISTS TO THE LEVEL OF THE DIAPHRAGM
ABDOMINAL AORTOGRAM:
FLUSH AORTOGRAM PERFORMED FROM THE TRUE LUMEN DEMONSTRATES A LARGE NATUR L
FENESTRATION JUST ABOVE THE LEVEL OF THE RENAL ARTERIES. THERE IS BRISK
FILLING OF THE FALSE LUMEN, BUT NO APPRECIABLE OUTFLOW IS DEMONSTRATED I
THE CHEST OR ABDOMEN.
AFTER EVALUATING THESE FINDINGS AND CONSIDERING THE LIKELIHOOD OF BENEFI
FROM MULTIPLE APPROACHES, AS WELL AS THE RISK OF POTENTIAL COMPLICATIONS
IT WAS DECIDED THE PATIENT WOULD NOT BENEFIT FROM THORACIC FENESTRATION;
HOWEVER, IT WAS FELT THAT THE PATIENT MAY BENEFIT FROM INCREASING THE
OUTFLOW OF THIS FALSE LUMEN AND HOPEFULLY PREVENT ANY PROXIMAL MIGRATION OR
EXTENSION OF THE FALSE LUMEN.
A WIRE WAS PASSED: FROM THE LEFT GROIN ACCESS SITE INTO THE FALSE LUMEN D WN
TO THE MOST INFERIOR ASPECT OF THE FALSE LUMEN WHICH WAS LOCATED IN THE
DISTAL COMMON ILIAC ARTERY.
FROM THE RIGHT GROIN ACCESS SITE, WHICH WAS IN THE TRUE LUMEN, AN ACCESS
WAS MADE INTO THE FALSE LUMEN IN THE REGION OF THE COMMON ILIAC ARTERY. £HE
WIRE FROM THE LEFT GROIN WAS THEN CAPTURED AND PULLED THROUGH THE RIGHT
GROIN ACCESS SHEATH. USING THE “CHEESE GRATER TECHNIQUE”, THE WIRE WAS
PULLED TO INCREASE THE SIZE OF THE FENESTRATION IN THE ABDOMINAL AORTA.
AFTER DOING THIS, FLOW-LIMITING NARROWING WAS PRESENT IN THE ORIGIN OF T
RIGHT COMMON ILIAC ARTERY, AND AN 8 MM ANGIOPLASTY BALLOON WAS THEN
ADVANCED OVER THE. WIRE AND INFLATED ACROSS THIS REGION. THIS SIGNIFICANT
IMPROVED THE FLOW: TO THE RIGHT LEG.
IMPRESSION:
1. FINDINGS CONSISTENT WITH PATIENT'S KNOWN HISTORY OF ACUTE TYPE-B
DISSECTION WITH A NATURAL FENESTRATION IN THE ABDOMINAL AORTA JUST
ABOVE THE LEVEL OF THE RENAL ARTERIES. THIS DISSECTION DOES EXTEND
PROXIMALLY TO THE. LEVEL JUST DISTAL TO THE ORIGIN OF THE LEFT
SUBCLAVIAN ARTERY. THERE IS NO EVIDENCE OF FENESTRATION IN THE CHEST.
FURTHERMORE, FLOW. IN THE THORACIC PORTION OF THIS DISSECTION IS VERY
SLUGGISH; THERE IS A LARGE AMOUNT OF THROMBUS WITHIN THE FALSE LUMEN
IN THE TRANSVERSE ARCH AND THE DISTAL ASPECTS OF THE TRANSVERSE ARCH
AND PROXIMAL DESCENDING AORTA.
2. AFTER EXTENDING THE FENESTRATION THROUGH THE ABDOMINAL AORTA AND
PRESERVING FLOW TO THE RIGHT COMMON ILIAC ARTERY, ANGIOGRAPHIC RUNS
DEMONSTRATE PRESERVED FLOW TO BOTH LOWER EXTREMITIES.
3. THE INTENT OF CREATING/EXTENDING THIS FENESTRATION INFERIORLY WAS T)
HOPEFULLY PREVENT: ANY FURTHER PROXIMAL EXTENSION OF THIS DISSECTION.
