I was approached with this case, and am wanting to suggest 93456 for the pressures of RV, RA, and PA along with the pulmonary angio. Is this the right thought process? Any guidance is appreciated. Thanks!
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HISTORY/INDICATION: 68-year-old with bilateral pulmonary embolism with elevated troponin and RV/LV ratio and worsening shortness of breath. Presenting for pulmonary angiogram with possible interventions.
PHYSICIANS/OPERATORS
1. John Irish, M.D. (IR Attending)
2. Ting-Chang Sheu, D.O. (IR Resident)
PROCEDURE:
1. Ultrasound-guided right common femoral vein access.
2. Pressure measurements in the right atrium, right ventricle, main pulmonary trunk.
3. Pulmonary angiogram.
4. Suction thrombectomy with AlphaVac device in the right pulmonary arteries.
5. Completion pulmonary angiogram and pressure measurements.
MEDICATION:
Fentanyl 100 mcg IV
Lidocaine 1% subcutaneous.
SEDATION FACE-TO-FACE TIME: 26 minutes. Moderate conscious sedation with fentanyl.
CONTRAST: 97 mL of Isovue-300.
FLUOROSCOPY DOSE: Total fluoroscopy time was 9.1 minutes. Dose area product (DAP): 121.22 Gy*cm2
TECHNIQUE:
Written informed consent was obtained from the patient after a thorough discussion of the risks, benefits, and alternatives to the procedure. All questions were answered appropriately and thoroughly. The patient was then taken to the interventional radiology suite and placed supine on the table. A "timeout" was performed prior to the procedure to verify the patient's name, birthdate, and site as well as the type of procedure to be performed. Once appropriate site for skin entry was identified, the right groin was prepped and draped in the standard sterile fashion using maximum sterile barrier techniques. The ultrasound transducer was sterilely prepped.
Skin and soft tissues of the right groin were anesthetized with 1% lidocaine and a small dermatotomy made. Under direct sonographic visualization, a 21-gauge micropuncture needle was advanced into the right common femoral vein and exchanged over-the-wire for a transitional dilator. The transitional dilator was exchanged for a 5 French by 11 cm access sheath. Over a Bentson guidewire, a 5 French pigtail flush catheter was carefully advanced into the IVC and formed. Next, the flush catheter was advanced to the right atrium where pressure was measured and was 11 mmHg. The flush catheter was then advanced to the right ventricle where pressure was measured to be 15 mmHg. Finally, the catheter was advanced to the main pulmonary trunk and the pressure was measured to be 63/17 (34). Next, an Amplatz superstiff wire was advanced through the pigtail catheter in place within the distal right main pulmonary artery, and the flush catheter and the short right groin sheath were removed and exchanged for a 22 French Gore dry seal sheath. Through the sheath, the sheath was advanced followed by insertion of the device and advanced to the right upper lobar pulmonary arteries. Multiple passes were performed with small to moderate amounts of clot removed. Completion pulmonary angiogram demonstrated that there was likely improvement of flow in the right upper pulmonary arteries. Over the wire, the pigtail flush catheter was again advanced to the IVC and formed. The pigtail flush catheter was 1st advanced to the right atrium and the pressure was measured to be 11 mmHg. Next, the flush catheter was advanced to the right ventricle and the pressure was measured to be 4 mmHg. Finally, the flush catheter was advanced to the main pulmonary trunk and the pressure was 51/15 (25).
The right groin sheath as well as all catheters and wires were removed, and manual pressure was held to ensure hemostasis. The skin was cleansed and a sterile dressing applied.
The patient's cardiopulmonary status was monitored throughout the procedure by interventional radiology nursing staff, myself, and the attending interventional radiologist. The patient received moderate conscious sedation during this procedure. There were no immediate complications and the patient tolerated the procedure well. All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
IMPRESSION:
1. Successful uncomplicated AlphaVac suction thrombectomy in the right pulmonary arteries with removal of small to moderate amount of clot. Pressure measurements before and after intervention as above.
------------------------------------
HISTORY/INDICATION: 68-year-old with bilateral pulmonary embolism with elevated troponin and RV/LV ratio and worsening shortness of breath. Presenting for pulmonary angiogram with possible interventions.
PHYSICIANS/OPERATORS
1. John Irish, M.D. (IR Attending)
2. Ting-Chang Sheu, D.O. (IR Resident)
PROCEDURE:
1. Ultrasound-guided right common femoral vein access.
2. Pressure measurements in the right atrium, right ventricle, main pulmonary trunk.
3. Pulmonary angiogram.
4. Suction thrombectomy with AlphaVac device in the right pulmonary arteries.
5. Completion pulmonary angiogram and pressure measurements.
MEDICATION:
Fentanyl 100 mcg IV
Lidocaine 1% subcutaneous.
SEDATION FACE-TO-FACE TIME: 26 minutes. Moderate conscious sedation with fentanyl.
CONTRAST: 97 mL of Isovue-300.
FLUOROSCOPY DOSE: Total fluoroscopy time was 9.1 minutes. Dose area product (DAP): 121.22 Gy*cm2
TECHNIQUE:
Written informed consent was obtained from the patient after a thorough discussion of the risks, benefits, and alternatives to the procedure. All questions were answered appropriately and thoroughly. The patient was then taken to the interventional radiology suite and placed supine on the table. A "timeout" was performed prior to the procedure to verify the patient's name, birthdate, and site as well as the type of procedure to be performed. Once appropriate site for skin entry was identified, the right groin was prepped and draped in the standard sterile fashion using maximum sterile barrier techniques. The ultrasound transducer was sterilely prepped.
Skin and soft tissues of the right groin were anesthetized with 1% lidocaine and a small dermatotomy made. Under direct sonographic visualization, a 21-gauge micropuncture needle was advanced into the right common femoral vein and exchanged over-the-wire for a transitional dilator. The transitional dilator was exchanged for a 5 French by 11 cm access sheath. Over a Bentson guidewire, a 5 French pigtail flush catheter was carefully advanced into the IVC and formed. Next, the flush catheter was advanced to the right atrium where pressure was measured and was 11 mmHg. The flush catheter was then advanced to the right ventricle where pressure was measured to be 15 mmHg. Finally, the catheter was advanced to the main pulmonary trunk and the pressure was measured to be 63/17 (34). Next, an Amplatz superstiff wire was advanced through the pigtail catheter in place within the distal right main pulmonary artery, and the flush catheter and the short right groin sheath were removed and exchanged for a 22 French Gore dry seal sheath. Through the sheath, the sheath was advanced followed by insertion of the device and advanced to the right upper lobar pulmonary arteries. Multiple passes were performed with small to moderate amounts of clot removed. Completion pulmonary angiogram demonstrated that there was likely improvement of flow in the right upper pulmonary arteries. Over the wire, the pigtail flush catheter was again advanced to the IVC and formed. The pigtail flush catheter was 1st advanced to the right atrium and the pressure was measured to be 11 mmHg. Next, the flush catheter was advanced to the right ventricle and the pressure was measured to be 4 mmHg. Finally, the flush catheter was advanced to the main pulmonary trunk and the pressure was 51/15 (25).
The right groin sheath as well as all catheters and wires were removed, and manual pressure was held to ensure hemostasis. The skin was cleansed and a sterile dressing applied.
The patient's cardiopulmonary status was monitored throughout the procedure by interventional radiology nursing staff, myself, and the attending interventional radiologist. The patient received moderate conscious sedation during this procedure. There were no immediate complications and the patient tolerated the procedure well. All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
IMPRESSION:
1. Successful uncomplicated AlphaVac suction thrombectomy in the right pulmonary arteries with removal of small to moderate amount of clot. Pressure measurements before and after intervention as above.