TIPS Procedure with Thrombectomy

uneeq3

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Hello again my IR friends, I'm having an issue with this case. I'm confused about mechanical venous thrombectomy and venous aspiration thrombectomy. As always, I appreciate your time.

So going through this report, the codes I come up with are:

37182 - TIPS
37187- VenousThrombectomy ???
36011- Selective placement hepatic vein.
37212 - Venous thrombolysis infusion
76937 - Us gdn

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT, THROMBECTOMY OF THE PORTAL VEIN AND SUPERIOR MESENTERIC VEIN

PRE-PROCEDURE DIAGNOSIS: Portal-mesenteric venous thrombosis, severe abdominal pain, leukocytosis and elevated lactic acid levels concerning for bowel ischemia.

POST-PROCEDURE DIAGNOSIS: Portal-mesenteric venous thrombosis, severe abdominal pain, leukocytosis and elevated lactic acid levels concerning for bowel ischemia.

PROCEDURES PERFORMED:

1. Transjugular intrahepatic portosystemic shunt insertion
2. Fluoroscopically guided aspiration thrombectomy of the portal vein and superior mesenteric vein.

MEDICATIONS: 5 cc 1% lidocaine subcutaneous, 175 Visipaque IV, 1 gram Ancef IV. General anesthesia was administered and monitored by the anesthesiologist.

KERMA-AREA-PRODUCT (PKA): 1452 Gy cm2

FINDINGS/TECHNIQUE: The risks and benefits of the procedure were discussed with the patient, including the possibility of hepatic encephalopathy, hemorrhage, or death. The risks of not undergoing the procedure were also discussed. Informed consent was obtained. The patient was placed supine on the fluoroscopy table. After induction of general anesthesia by the anesthesiologist, the right neck was prepped and draped using maximum sterile barrier technique. Ultrasound exam of the right neck was performed to evaluate for potential access sites, demonstrating patency of the right internal jugular vein. 1% lidocaine was administered subcutaneously and a small dermatotomy was made with an 11 blade.

A micropuncture needle was advanced into the right internal jugular vein under real-time ultrasound guidance, an image stored for the patient's records. The needle was exchanged over a microwire for a micropuncture sheath. A Bentson wire was advanced through the sheath to the IVC. The micropuncture sheath was exchanged over the wire for an MPB catheter. The right hepatic vein was selectively catheterized and right hepatic venography was performed, demonstrating patency of the right hepatic vein. The catheter was removed over an Amplatz wire. A 10-French dilator was advanced over the wire into the jugular vein. Then a 10-French TIPS sheath was advanced over the wire to the right hepatic vein. A balloon occlusion catheter was advanced over the wire to the right hepatic vein. The balloon was inflated to occlude the hepatic vein. Carbon dioxide portal venography was performed, which did not result in opacification of the portal veins. The balloon occlusion catheter was deflated and removed over an Amplatz wire. The Colapinto needle and sheath were advanced over the wire to the right hepatic vein. The Colapinto needle was passed through the liver multiple times and pulled back until there was blood return. Contrast injection confirmed opacification of the portal vein.

A glidewire was advanced through the Colapinto needle to the main portal vein under fluoroscopic guidance. The needle was removed over the wire and a glide catheter was advanced over the wire to the portal vein. The needle sheath and tip sheath were advanced over the Colapinto needle and Glidewire into the main portal vein. Portal venography was performed, demonstrating partially occlusive thrombus in the main portal vein, opacification of right hepatic portal venous branches, and little opacification of the left hepatic portal venous system. Then a 6/2 cm Viatorr stent was deployed from the portal vein to the right hepatic vein under fluoroscopic guidance, postdilated to 5 mm. Post TIPS portal venogram demonstrated some flow through the TIPS with preserved flow to the right portal venous system.

Using a CAT 7 aspiration catheter, aspiration thrombectomy of the portal vein and superior mesenteric vein was performed under fluoroscopic guidance. Repeat portal venogram demonstrated significant residual thrombus burden.

The TIPS sheath was upsized to a 12 French sheath. Using a CAT 12 aspiration catheter, further thrombectomy of the portal vein and superior mesenteric vein was performed under fluoroscopic guidance. Post thrombectomy venogram demonstrated some restored flow through a few superior mesenteric venous branches and up the superior mesenteric to the portal vein. There was some residual thrombus in the main portal vein adjacent to the bare-metal end of the TIPS.

A multi-sidehole infusion catheter was placed in the superior mesenteric vein and portal vein for overnight TPA infusion. The sheath was secured to the skin at the exit site with 0 silk suture and a dressing was applied.

The patient tolerated the procedure well without any immediate complication.

IMPRESSION:

SUCCESSFUL TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT INSERTION.

SUCCESSFUL FLUOROSCOPICALLY GUIDED THROMBECTOMY OF THE SUPERIOR MESENTERIC VEIN AND PORTAL VEIN. THERE WAS SOME RESIDUAL THROMBUS WITHIN SUPERIOR MESENTERIC VEIN BRANCHES IN THE MAIN PORTAL VEIN. THEREFORE, A MULTI-SIDEHOLE INFUSION CATHETER WAS PLACED FOR OVERNIGHT TPA INFUSION.
 

Jim Pawloski

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37187 is a thrombectomy, no matter how you get the clot out. The only thing that I would change is 36011 to 36012 for second order selective venous for the SMV.
 

uneeq3

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Hi Jim, thank you for responding. I thought aspiration thrombectomy was a code different from mechanical. Another lesson learned. Thanks again for taking the time.

Lisa, COC :)
 
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