As a new vascular coder i am struggling with this case and what is bundled. There were three different days of serivce. I know this case is long but any help would be appreciated.
This is what I have so far: 76937, 36010, 75825, 37620, 75940 for IVC filter
36556, 37201, 75896 (for the last 3 items)
Day 1
POSTOPERATIVE DIAGNOSIS: Large deep venous thrombosis of left lower extremity involving the popliteal, common femoral and common iliac veins.
PROCEDURES PERFORMED:
1. Ultrasound-guided access right internal jugular.
2. Catheter in inferior vena cava.
3. Inferior vena cava venogram.
4. Inferior vena cava filter placement.
5. Ultrasound-guided access into the left gastroc vein.
6. Left lower extremity venogram.
7. Catheter placement into the left external iliac.
8. Left external iliac and inferior vena cava venogram.
9. Angioplasty of left femoral vein.
10. Placement of a 5-French 90 cm length catheter, 50 cm infusion length Unifuse lysis catheter extending from the tip location in the common iliac vein on the left down to the popliteal vein on the left.
11. Ultrasound-guided access into the gastroc vein on the left.
12. Triple-lumen catheter placement right internal jugular.
13. Initiation of lysis therapy via UniFuse lytic catheter.
DESCRIPTION OF PROCEDURE:
Under ultrasound guidance an 18-gauge needle was placed into the right IJ. The ultrasound was used to avoid injuring surrounding structures and image was saved in archives. Under fluoroscopic guidance a Bentson wire was passed into the IVC and subsequently the tract was dilated with a 10 French sheath followed by the placement of the delivery sheath for the filter into the IVC. An IVC venogram was then performed.
The right common iliac vein is widely patent with slow flow out of the left common iliac vein. The IVC appears to be widely patent with no evidence of any thrombus and the renal veins enter the IVC at the bottom of L1. At this time, a Cook Celect filter was advanced through the sheath and was deployed under fluoroscopic guidance with the tip of the filter located at the top of L1. There was no tilt noted on the IVC filter after placement.
At this time a Bentson wire was advanced through the sheath followed by placement of a triple lumen catheter with the tip of the catheter located into the right atrium. All three ports of the triple lumen catheter were flushed and withdrew easily and the catheter was then secured into position with 3-0 Ethilon sutures. The patient was then taken off the table and then replaced onto the table in a supine position. The left popliteal fossa was then prepped and draped in sterile fashion. Timeout was once again performed identifying the patient's name, medical record number and the procedure to be performed.
Under ultrasound guidance a 21-gauge needle was placed into the left gastroc vein which rapidly entered into the popliteal vein. Mandril wire was placed followed by a 5-French sheath and a Kumpe catheter was then used to enter into the popliteal vein. A left lower extremity venogram was then performed showing a complete occlusion of the femoral vein as well as multiple collaterals throughout the left thigh. The Kumpe catheter was used to try to cross the femoral vein, but it was noted to be very difficult and at this time I switched out to a Quick Cross catheter and a Glidewire to cross the femoral vein. There was significant difficulty crossing the mid femoral vein and it was suspicious at this time that some of this thrombus could have been chronic in nature. At this time an Amplatz wire was left in place and the mid femoral vein was then angioplastied with a 4 mm diameter x 4 cm P3 balloon. This allowed for passage of UniFuse lytic catheter. The Quick Cross catheter was then advanced into the external iliac artery and another venogram was performed to evaluate the left external and left common iliac veins. These veins were noted to have significant acute thrombus. At this time the 5 x 90 x 50 UniFuse catheter was advanced under fluoroscopic guidance with the tip located into the common iliac vein on the left and with the entire infusion length coat passing through the left external, left common, left femoral and left popliteal veins. At this time, the catheters were secured and TPA lysis was initiated in through the sheath at 0.5 mg of TPA per hour. The heparin was flushed through a 6-French sheath that is located through the gastroc vein entering into the popliteal vein at 1000 units per hour. The patient will return in 24 hours to have a followup lysis venogram performed.
Day 2
ROCEDURES PERFORMED: Follow up venogram at 24 hours status post 24 hours of tissue plasminogen activator lysis left lower extremity.
DESCRIPTION OF PROCEDURE: the catheters located in the left popliteal fossa were then prepped and draped in sterile fashion. At this time the injection of contrast first through the sheath was performed showing a significant collateralization throughout the left thigh. There were some flow disturbances within some of the collaterals but the collaterals do fill rapidly into the common femoral vein which was now patent. Subsequently another injection was performed through the indwelling lysis catheter. This identified once again an evidence of chronic thrombus throughout the left femoral vein with approximately a 50% thrombus resolvement in the left common femoral vein, left external iliac vein and left common iliac veins. At this time it was felt best to continue TPA lysis. There was no manipulation of catheters and the sheaths and catheters were then flushed thoroughly and continuation of TPA lysis at 0.5 mg TPA per hour was continued through the lysis catheter and heparin was continued at 1000 units per hour through the sheath. The patient was then taken back to the ICU in stable condition.
FINAL IMPRESSION:
1. Evidence of chronic thrombus within the left femoral vein.
2. Acute thrombus within the left common femoral vein, left external iliac vein and left common iliac veins have been reduced by approximately 50-60%.
3. Continuation of tissue plasminogen activator lysis at 0.5 mg per hour of tissue plasminogen activator.
Day 3
PROCEDURES PERFORMED:
1. Followup venogram status post 48 hours of tissue plasminogen activator lysis of left lower extremity.
2. Angioplasty of left popliteal vein.
3. Angioplasty left femoral vein.
4. Angioplasty left common femoral vein.
5. Angioplasty left external iliac vein.
6. Stent left femoral vein using an 8 x 60 Smart and an 8 x 40 Smart.
7. Repeat followup venogram.
8. Placement of a new Unifuse 5 x 90 x 50 lytic catheter.
9. Continuation of tissue plasminogen activator lysis.
DESCRIPTION OF PROCEDURE: The left popliteal fossa was then prepped and draped in sterile fashion.
Contrast was first injected through the sheath and subsequently the UniFuse catheter to identify once again multiple collaterals throughout the left thigh and still no opening of the left femoral vein. However, collaterals rapidly filled into the common femoral vein which appeared to have resolvement of the acute thrombus. There was, however, still a significant stenosis in the left common femoral, left and left external iliac veins at this time.
The catheter was then changed out for an Amplatz wire, and serial angioplasties were performed of the left external iliac, left common femoral, left femoral, left popliteal veins. The first angioplasty series was run with a 5 x 100 P3 balloon, and subsequently by a 7 x 100 P3 balloon. After the angioplasty with the 7 mm balloon, a repeat venogram was performed showing some decent flow through the femoral vein but a significant stenosis that is residual despite two angioplasties in the mid femoral vein. At this time, a third angioplasty was then performed using a 10 mm x 6 cm P3 balloon. This angioplasty was performed of the left external iliac, left common femoral, left femoral veins down to and including the left popliteal vein. Upon completion, a repeat venogram was performed, and the central portion of the left femoral vein was still significantly stenosed and did not allow free flow of contrast. At this time, an 8 x 60 and an 8 x 40 Smart stents were then deployed under fluoroscopic guidance and then angioplastied with the 10 mm balloon. Contrast injection now showed acute thrombus within the left femoral vein. However, there was significant improvement compared to the preangioplasty and pre-stenting. A Unifuse lytic catheter measuring 50 x 90 x 5-French was then replaced into the left lower extremity venous system extending from the common iliac vein down to the popliteal, and lysis was continued for another 24 hours at 0.5 mg of t-PA per hour.
FINAL IMPRESSION:
1. Chronic thrombus and severe stenosis of the left femoral vein that was angioplastied with serial balloons starting with a 5 mm, followed by a 7 mm, followed by a 10 mm balloon and subsequently placement of an 8 mm Smart stents.
2. Repeat angioplasties and angiograms now identifies an acute thrombus within the left femoral vein and left common femoral vein. Subsequently, t-PA lysis was continued by the placement of another UniFuse catheter and continued t-PA at 0.5 mg per hour. She will return in 24 hours for her 72-hour followup.
This is what I have so far: 76937, 36010, 75825, 37620, 75940 for IVC filter
36556, 37201, 75896 (for the last 3 items)
Day 1
POSTOPERATIVE DIAGNOSIS: Large deep venous thrombosis of left lower extremity involving the popliteal, common femoral and common iliac veins.
PROCEDURES PERFORMED:
1. Ultrasound-guided access right internal jugular.
2. Catheter in inferior vena cava.
3. Inferior vena cava venogram.
4. Inferior vena cava filter placement.
5. Ultrasound-guided access into the left gastroc vein.
6. Left lower extremity venogram.
7. Catheter placement into the left external iliac.
8. Left external iliac and inferior vena cava venogram.
9. Angioplasty of left femoral vein.
10. Placement of a 5-French 90 cm length catheter, 50 cm infusion length Unifuse lysis catheter extending from the tip location in the common iliac vein on the left down to the popliteal vein on the left.
11. Ultrasound-guided access into the gastroc vein on the left.
12. Triple-lumen catheter placement right internal jugular.
13. Initiation of lysis therapy via UniFuse lytic catheter.
DESCRIPTION OF PROCEDURE:
Under ultrasound guidance an 18-gauge needle was placed into the right IJ. The ultrasound was used to avoid injuring surrounding structures and image was saved in archives. Under fluoroscopic guidance a Bentson wire was passed into the IVC and subsequently the tract was dilated with a 10 French sheath followed by the placement of the delivery sheath for the filter into the IVC. An IVC venogram was then performed.
The right common iliac vein is widely patent with slow flow out of the left common iliac vein. The IVC appears to be widely patent with no evidence of any thrombus and the renal veins enter the IVC at the bottom of L1. At this time, a Cook Celect filter was advanced through the sheath and was deployed under fluoroscopic guidance with the tip of the filter located at the top of L1. There was no tilt noted on the IVC filter after placement.
At this time a Bentson wire was advanced through the sheath followed by placement of a triple lumen catheter with the tip of the catheter located into the right atrium. All three ports of the triple lumen catheter were flushed and withdrew easily and the catheter was then secured into position with 3-0 Ethilon sutures. The patient was then taken off the table and then replaced onto the table in a supine position. The left popliteal fossa was then prepped and draped in sterile fashion. Timeout was once again performed identifying the patient's name, medical record number and the procedure to be performed.
Under ultrasound guidance a 21-gauge needle was placed into the left gastroc vein which rapidly entered into the popliteal vein. Mandril wire was placed followed by a 5-French sheath and a Kumpe catheter was then used to enter into the popliteal vein. A left lower extremity venogram was then performed showing a complete occlusion of the femoral vein as well as multiple collaterals throughout the left thigh. The Kumpe catheter was used to try to cross the femoral vein, but it was noted to be very difficult and at this time I switched out to a Quick Cross catheter and a Glidewire to cross the femoral vein. There was significant difficulty crossing the mid femoral vein and it was suspicious at this time that some of this thrombus could have been chronic in nature. At this time an Amplatz wire was left in place and the mid femoral vein was then angioplastied with a 4 mm diameter x 4 cm P3 balloon. This allowed for passage of UniFuse lytic catheter. The Quick Cross catheter was then advanced into the external iliac artery and another venogram was performed to evaluate the left external and left common iliac veins. These veins were noted to have significant acute thrombus. At this time the 5 x 90 x 50 UniFuse catheter was advanced under fluoroscopic guidance with the tip located into the common iliac vein on the left and with the entire infusion length coat passing through the left external, left common, left femoral and left popliteal veins. At this time, the catheters were secured and TPA lysis was initiated in through the sheath at 0.5 mg of TPA per hour. The heparin was flushed through a 6-French sheath that is located through the gastroc vein entering into the popliteal vein at 1000 units per hour. The patient will return in 24 hours to have a followup lysis venogram performed.
Day 2
ROCEDURES PERFORMED: Follow up venogram at 24 hours status post 24 hours of tissue plasminogen activator lysis left lower extremity.
DESCRIPTION OF PROCEDURE: the catheters located in the left popliteal fossa were then prepped and draped in sterile fashion. At this time the injection of contrast first through the sheath was performed showing a significant collateralization throughout the left thigh. There were some flow disturbances within some of the collaterals but the collaterals do fill rapidly into the common femoral vein which was now patent. Subsequently another injection was performed through the indwelling lysis catheter. This identified once again an evidence of chronic thrombus throughout the left femoral vein with approximately a 50% thrombus resolvement in the left common femoral vein, left external iliac vein and left common iliac veins. At this time it was felt best to continue TPA lysis. There was no manipulation of catheters and the sheaths and catheters were then flushed thoroughly and continuation of TPA lysis at 0.5 mg TPA per hour was continued through the lysis catheter and heparin was continued at 1000 units per hour through the sheath. The patient was then taken back to the ICU in stable condition.
FINAL IMPRESSION:
1. Evidence of chronic thrombus within the left femoral vein.
2. Acute thrombus within the left common femoral vein, left external iliac vein and left common iliac veins have been reduced by approximately 50-60%.
3. Continuation of tissue plasminogen activator lysis at 0.5 mg per hour of tissue plasminogen activator.
Day 3
PROCEDURES PERFORMED:
1. Followup venogram status post 48 hours of tissue plasminogen activator lysis of left lower extremity.
2. Angioplasty of left popliteal vein.
3. Angioplasty left femoral vein.
4. Angioplasty left common femoral vein.
5. Angioplasty left external iliac vein.
6. Stent left femoral vein using an 8 x 60 Smart and an 8 x 40 Smart.
7. Repeat followup venogram.
8. Placement of a new Unifuse 5 x 90 x 50 lytic catheter.
9. Continuation of tissue plasminogen activator lysis.
DESCRIPTION OF PROCEDURE: The left popliteal fossa was then prepped and draped in sterile fashion.
Contrast was first injected through the sheath and subsequently the UniFuse catheter to identify once again multiple collaterals throughout the left thigh and still no opening of the left femoral vein. However, collaterals rapidly filled into the common femoral vein which appeared to have resolvement of the acute thrombus. There was, however, still a significant stenosis in the left common femoral, left and left external iliac veins at this time.
The catheter was then changed out for an Amplatz wire, and serial angioplasties were performed of the left external iliac, left common femoral, left femoral, left popliteal veins. The first angioplasty series was run with a 5 x 100 P3 balloon, and subsequently by a 7 x 100 P3 balloon. After the angioplasty with the 7 mm balloon, a repeat venogram was performed showing some decent flow through the femoral vein but a significant stenosis that is residual despite two angioplasties in the mid femoral vein. At this time, a third angioplasty was then performed using a 10 mm x 6 cm P3 balloon. This angioplasty was performed of the left external iliac, left common femoral, left femoral veins down to and including the left popliteal vein. Upon completion, a repeat venogram was performed, and the central portion of the left femoral vein was still significantly stenosed and did not allow free flow of contrast. At this time, an 8 x 60 and an 8 x 40 Smart stents were then deployed under fluoroscopic guidance and then angioplastied with the 10 mm balloon. Contrast injection now showed acute thrombus within the left femoral vein. However, there was significant improvement compared to the preangioplasty and pre-stenting. A Unifuse lytic catheter measuring 50 x 90 x 5-French was then replaced into the left lower extremity venous system extending from the common iliac vein down to the popliteal, and lysis was continued for another 24 hours at 0.5 mg of t-PA per hour.
FINAL IMPRESSION:
1. Chronic thrombus and severe stenosis of the left femoral vein that was angioplastied with serial balloons starting with a 5 mm, followed by a 7 mm, followed by a 10 mm balloon and subsequently placement of an 8 mm Smart stents.
2. Repeat angioplasties and angiograms now identifies an acute thrombus within the left femoral vein and left common femoral vein. Subsequently, t-PA lysis was continued by the placement of another UniFuse catheter and continued t-PA at 0.5 mg per hour. She will return in 24 hours for her 72-hour followup.
