TIPS eval

stgregor

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Tacoma, WA
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Thoughts on coding for this? I coded 36011, 36481, 75885 (since it doesn't appear hepatic venography was performed).

EXAM DESCRIPTION: Transjugular intrahepatic portosystemic shunt
evaluation.

INDICATION: hepatitis C and endstage liverdisease, had a transjugular intrahepatic portosystemic shunt placed in February, revised in September. Followup ultrasound showed elevated velocities in the mid portion of the shunt, concerning for possible stenosis.Angiography requested.

OPERATIONS
1. Ultrasound-guided access of the left internal jugular vein.
2. Placement of a 6-French sheath into the right atrium with
hemodynamic pressure monitoring here.
3. Cannulation of the portosystemic shunt with placement of a pigtail
catheter in the portal vein.
4. Hemodynamic pressure monitoring in the portal vein.
5. Portal and shunt venogram.

TECHNIQUE
After procedure, alternatives, risks, and questions (PARQ) conference
was held and informed consent obtained, the patient was placed supine
on the angiography table and the left lower neck prepped and draped
in sterile fashion. Skin and subcutaneous tissues were anesthetized
with 1% buffered lidocaine. Under ultrasound guidance, the left
internal jugular vein was accessed with the micropuncture set and a
0.035-inch wire passed to the inferior vena cava (IVC). A 6-French
sheath was placed over the wire with tip in the right atrium.
Hemodynamic pressure monitoring was performed here.
A 5-French Levin catheter and wire were passed through the sheath and
used to cannulate the right hepatic vein and transjugular
intrahepatic portosystemic shunt (TIPS) shunt with wire placed
distally in the portal vein. The catheter was exchanged for a
5-French pigtail catheter. With this in the portal vein, hemodynamic
pressure monitoring was performed. This was followed by contrast
injection for portal and shunt venogram.
The catheter was removed over a wire. The patient was transferred to
his bed and the sheath removed and manual pressure held until
hemostasis achieved. Sterile bandage was applied. The patient
tolerated the procedure well without immediate complications and was
transferred back to the recovery area in stable condition for
observation.

FINDINGS:
Right atrial pressure was 5 mmHg and portal vein pressure 15 mmHg,
for a gradient of 10 mmHg. Main portal vein is normal in caliber. Two
overlapping stents are in place for the portosystemic shunt from the
main portal vein to the right hepatic vein. The hepatic vein end is
approximately 3 cm from the right atrium. There is brisk flow
throughout the main portal vein into the shunt, right hepatic vein,
and right atrium. There is no evidence of stenosis anywhere within
the shunt. No antegrade flow is visible in distal portal vein
branches. Clips in the right upper quadrant are compatible with
cholecystectomy.
CONCLUSION
1. Widely patent intrahepatic portosystemic shunt with brisk flow and
no evidence of stenosis.
2. Portal vein to right atrium pressure gradient of 10 mmHg.
 
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