Hello I am new at Interventional Rad. I have a case where I feel confuse. When I first read it my impresion was since it was through the vertebral Artery i thought of 61626 but then i've got a sec opinion 
At first I have Coded it as follow:
61626
36217
75894,26
75898,26
75685,26
Then I asked a co-worker and he came out with a diferent set as follow:
61624
36217
36218,59 x 2
75898,26 x 2
75894,26
75685,26
75774,26,59 x 3
Here is the report and I am so sorry for the Caps. it was extracted from a program that won't allow me to change it . Thanks for your time and assitance.
Report:
VESSELS INJECTED-
RIGHT VERTEBRAL ARTERY,
SUPERSELECTIVE RIGHT P3-PCA, PARIETAL-OCCIPITAL (PO) DIVISION
SUPERSELECTIVE RIGHT P4-PCA, PARIETAL-OCCIPITAL (TO) DIVISION
SUPERSELECTIVE RIGHT P4-PCA X 2
ABDOMINAL AORTA
OPERATIONS/PROCEDURES- THE PROCEDURES, RISKS (INCLUDING STROKE,
DEATH, BLEEDING, COMA, DAMAGE TO BLOOD VESSELS, INFECTION, AND
ADVERSE REACTION TO MEDICATIONS), BENEFITS, AND ALTERNATIVES WERE
DISCUSSED WITH THE PATIENT AND HER FAMILY, IN WHICH ALL QUESTIONS
WERE ANSWERED AND INFORMED CONSENT WAS OBTAINED. THE PATIENT WAS
BROUGHT INTO THE NEURO-INTERVENTIONAL SUITE AND PLACED ON THE
FLUORO/DSA TABLE IN A SUPINE POSITION. A PROCEDURAL TIMEOUT WAS TAKEN
TO VERIFY THE CORRECT PATIENT AND INTERVENTION. BOTH GROINS WERE
PREPPED AND DRAPED IN THE USUAL STERILE FASHION.
THE RIGHT COMMON FEMORAL ARTERY WAS THEN ACCESSED VIA A MODIFICATION
OF THE SELDINGER TECHNIQUE USING SINGLE WALL PUNCTURE TECHNIQUE WITH
AN 18G SINGLEWALL NEEDLE. PULSATILE ARTERIALIZED FLOW WAS OBSERVED,
IN WHICH A GUIDEWIRE WAS THEN INSERTED AND POSITIONED INTO THE AORTA
UNDER FLUOROSCOPIC GUIDANCE. A #7 FRENCH 23 CENTIMETER SHEATH WAS
SUBSEQUENTLY COAXIALLY PLACED OVER A GUIDEWIRE THROUGH THE RIGHT CFA
ARTERIOTOMY AND CONNECTED TO A PRESSURIZED CONTINUOUS HEPARINIZED
NORMAL INFUSION.
A #6-FRENCH 070 NEURON GUIDING CATHETER/# 5-FRENCH NEURON SELECT
BERENSTEIN COMBINATION WAS ADVANCED OVER A 0.035" TERUMO GLIDEWIRE
INTO THE ASCENDING AORTA, AND THEN MANIPULATED SERIALLY INTO THE
RIGHT SUBCLAVIAN AND EVENTUALLY DISTAL RIGHT VERTEBRAL ARTERY UNDER
DSA SUBTRACTED FLUOROSCOPIC GUIDANCE FOR SELECTIVE CATHETER DSA AS
FOLLOWS-
THE RIGHT VERTEBRAL ARTERY WAS THEN SELECTIVELY CATHETERIZED IN WHICH
BIPLANE CEREBRAL ANGIOGRAPHY WAS PERFORMED WITH MULTIPLANAR VIEWS
OBTAINED.
FINDINGS ON SELECTIVE CATHETER DSA-
CEREBRAL ANGIOGRAPHY FROM RIGHT VERTEBRAL ARTERY CEREBRAL ANGIOGRAM
(MULTIPLANAR VIEWS)- THE CERVICAL PORTIONS OF THE RIGHT VERTEBRAL
ARTERY ARE OF NORMAL COURSE AND CALIBER. THERE IS NO REFLUX OF
CONTRAST INTO THE CONTRALATERAL LEFT VERTEBRAL ARTERY. THE BASILAR
ARTERY IS MODERATELY ECTATIC BUT NORMAL CALIBER. NORMAL RIGHT PICA
DISTRIBUTION. BILATERAL SUPERIOR CEREBELLAR ARTERIES ARE OF NORMAL
COURSE AND CALIBER. AGAIN NOTED IS A MEDIUM-SIZE BRAIN AVM SITUATED
WITHIN THE RIGHT OCCIPITAL LOBE. THE DISTAL PCA SUPPLY APPEARS TO
ARISE FROM A MAJOR (PRIMARY) TEMPORAL OCCIPITAL BRANCH WHICH GIVES
OFF TO PRINCIPAL FEEDING SUBPEDICLES (SUPERIOR AND INFERIOR). THE
DISTAL TERRITORY AND CORRESPONDING NIDAL COMPARTMENT FROM THE
PREVIOUSLY DESCRIBED MINOR TEMPORAL-OCCIPITAL BRANCH TO THE AVM IS
OCCLUDED. THE AVM SHOWS EVIDENCE OF CONGESTIVE VENOUS DRAINAGE AND
VENOUS ANEURYSM FORMATION. THERE ARE AT LEAST TWO INTRA-NIDAL
ANEURYSMS AS NOTED EARLIER. THE AVM NIDUS MEASURES APPROXIMATELY 2
CENTIMETERS IN GREATEST DIMENSION.
NEURO-ENDOVASCULAR SURGICAL PROCEDURES-
1. SUPERSELECTIVE ENDOVASCULAR SURGICAL EXPLORATION OF RIGHT P3-PCA
AND TWO SEPARATE RIGHT P4-PCA FEEDING BRANCHES OF BRAIN AVM
2. ULTRA-SUPERSELECTIVE MICROCATHETERIZATION AND TRANSARTERIAL
EMBOLIZATION USING LIQUID NON-ADHESIVE NIDAL EMBOLIZATION WITH
ETHYLENE VINYL ALCOHOL COPOLYMER (ONYX) OF SUPERIOR COMPARTMENT OF
BAVM VIA TERMINAL FEEDING PEDICLE ARISING FROM P4-PCA
PARIETAL-OCCIPITAL DIVISION.
3. ULTRA-SUPERSELECTIVE MICROCATHETERIZATION AND TRANSARTERIAL
EMBOLIZATION USING LIQUID NON-ADHESIVE NIDAL EMBOLIZATION WITH
ETHYLENE VINYL ALCOHOL COPOLYMER (ONYX) OF INFERIOR COMPARTMENT OF
BAVM VIA TERMINAL FEEDING PEDICLE ARISING FROM P4-PCA
PARIETAL-OCCIPITAL DIVISION.
ENDOVASCULAR SURGICAL EXPLORATION WAS PERFORMED BY SUPERSELECTIVE
MICROCATHETER TECHNIQUE TO DETERMINE THE FAVORABILITY OF THE LESION
FOR ULTRA SUPERSELECTIVE TRANS ARTERIAL EMBOLIZATION. A 1.5-FRENCH
MARATHON MICROCATHETER WITH A .008" MIRAGE MICROGUIDEWIRE WAS
NAVIGATED WITHIN THE INTRACRANIAL RIGHT POSTERIOR CIRCULATION UNDER
FLUOROSCOPIC GUIDANCE AND ROAD MAPPING. THE MICROCATHETER WAS FIRST
PLACED IN THE RIGHT P3-PCA SEGMENT.
SUPERSELECTIVE P3-PCA DSA- BIPLANE DSA SHOWS THE MICROCATHETER TO BE
IN NON-WEDGE POSITION OF THE DISTAL MAIN PCA TRUNK IN WHICH
DOWNSTREAM THERE IS A TORTUOUS DISTAL P4-PCA BRANCH THAT GIVES RISE
TO THE PRIMARY SUPPLY TO THE AVM ARISING FROM THE PARIETAL-OCCIPITAL
DIVISION. THERE APPEAR TO BE FISTULOUS COMPONENTS TO THE AVM AS WELL
AS COMPACT NIDUS. ULTRASUPERSELECTIVE MICROCATHETERIZATION WAS THEN
PERFORMED WITH DSA ROADMAPPING AND CONTINUOUS FLUOROSCOPY OF THE
UPPER TERMINAL P4-PCA FEEDING PEDICLE.
RIGHT P4-PCA FEEDING PEDICLE #1 (USS-DSA#2)- BIPLANE DSA FROM P4
TEMPORAL-OCCIPITAL TERMINAL SUPERIOR DIVISION INJECTIONS SHOW THE
CATHETER TO BE UNDER WEDGE CONDITIONS. THIS SHOWED DELAYED
ARTERIOVENOUS SHUNTING THROUGH A MIXED FISTULOUS AND PLEXIFORM NIDAL
SUPEROMEDIAL COMPARTMENT OF THE AVM. THIS BRANCH PROVIDES A SMALL
PORTION OF SUPPLY TO THE AVM. A NIDAL ANEURYSM IS AGAIN SEEN WITHIN
THIS COMPARTMENT.
ENDOVASCULAR SURGICAL OBLITERATION AVM COMPARTMENT #1- UNDER
CONTINUOUS FLUOROSCOPIC GUIDANCE AND BLANK SUBTRACTED FLUOROSCOPY, A
CONTINUOUS COLUMN OF ONYX 18 WAS VERY SLOWLY, AND INTERMITTENTLY
INJECTED INTO THE AVM NIDUS IN WHICH SIGNIFICANT RETROGRADE REFLUX
INTO THE PRIMARY FEEDING PEDICLE OCCURRED. THIS PERMITTED
SUBSEQUENTLY EXCELLENT FLOW CONTROLLED DISTAL EMBOLIZATION OF THE
TARGETED NIDUS. THE EMBOLIC AGENT SLOWLY PENETRATED WELL INTO THE
TARGETED COMPARTMENT OF THE AVM NIDUS RESULTING IN EXCELLENT
OBLITERATION OF A SIGNIFICANT PORTION OF THE INFERIOR COMPARTMENT THE
AVM. NO NONTARGET DELIVERY OF THE EMBOLIC AGENT WAS NOTED.
CONTROL DSA FROM SELECTIVE RIGHT VERTEBRAL INJECTION- BIPLANE DSA
SHOWS APPROXIMATELY 60% OVERALL NIDAL VOLUME REDUCTION OF THE AVM
WITH PRESERVATION OF THE PRINCIPAL DRAINING VEINS. THERE HAS BEEN
SIGNIFICANT REDUCTION IN OVERALL AV SHUNTING. THE DISTAL PCA
TERRITORIES WITHIN TEMPORAL AND PARIETAL LOBES APPEAR NORMAL, WITHOUT
EVIDENCE OF EMBOLIC OCCLUSION.
ENDOVASCULAR SURGICAL EXPLORATION WAS PERFORMED BY SUPERSELECTIVE
MICROCATHETER TECHNIQUE TO DETERMINE THE FAVORABILITY OF THE LESION
FOR ULTRA SUPERSELECTIVE TRANS ARTERIAL EMBOLIZATION. A 1.5-FRENCH
MARATHON MICROCATHETER WITH A .008" MIRAGE MICROGUIDEWIRE WAS
NAVIGATED WITHIN THE INTRACRANIAL RIGHT POSTERIOR CIRCULATION UNDER
FLUOROSCOPIC GUIDANCE AND ROAD MAPPING. THE MICROCATHETER WAS THEN
PLACED IN THE RIGHT P3-PCA SEGMENT. ULTRASUPERSELECTIVE
MICROCATHETERIZATION WAS THEN PERFORMED WITH DSA ROADMAPPING AND
CONTINUOUS FLUOROSCOPY OF THE LOWER, DOMINANT TERMINAL P4-PCA FEEDING
PEDICLE.
RIGHT P4-PCA FEEDING PEDICLE #2 (USS-DSA#4)- BIPLANE DSA FROM P4
PARIETAL-OCCIPITAL TERMINAL DIVISION INJECTIONS SHOW THE CATHETER TO
BE UNDER NEAR-WEDGE CONDITIONS. THIS SHOWED ARTERIOVENOUS SHUNTING
THROUGH A MIXED FISTULOUS AND PLEXIFORM NIDAL INFEROMEDIAL
COMPARTMENT OF THE AVM. NORMAL CORTICAL BRANCHES WERE NOT VISUALIZED
PROXIMAL TO THE SITE OF AV SHUNTING. NIDAL ANEURYSMS ARE AGAIN SEEN
WITHIN THIS COMPARTMENT.
ENDOVASCULAR SURGICAL OBLITERATION AVM COMPARTMENT #2- UNDER
CONTINUOUS FLUOROSCOPIC GUIDANCE AND BLANK SUBTRACTED FLUOROSCOPY, A
CONTINUOUS COLUMN OF ONYX 16 WAS VERY SLOWLY, AND INTERMITTENTLY
INJECTED INTO THE AVM NIDUS IN WHICH SIGNIFICANT RETROGRADE REFLUX
INTO THE PRIMARY FEEDING PEDICLE OCCURRED. THIS PERMITTED
SUBSEQUENTLY EXCELLENT FLOW CONTROLLED DISTAL EMBOLIZATION OF THE
TARGETED NIDUS. THE EMBOLIC AGENT SLOWLY PENETRATED WELL INTO THE
TARGETED COMPARTMENT OF THE AVM NIDUS RESULTING IN EXCELLENT
OBLITERATION OF A SIGNIFICANT PORTION OF THE INFERIOR COMPARTMENT THE
AVM. NO NONTARGET DELIVERY OF THE EMBOLIC AGENT WAS NOTED.
FINAL CONTROL DSA FROM SELECTIVE RIGHT VERTEBRAL INJECTION- BIPLANE
DSA SHOWS GREATER THAN 95% OVERALL NIDAL VOLUME REDUCTION OF THE AVM
WITH PRESERVATION OF THE PRINCIPAL DRAINING VEINS. THERE HAS BEEN
DRAMATIC REDUCTION IN OVERALL AV SHUNTING. THE DISTAL PCA TERRITORIES
WITHIN TEMPORAL AND PARIETAL LOBES APPEAR NORMAL, WITHOUT EVIDENCE OF
EMBOLIC OCCLUSION. THERE IS EN PASSANT SUPPLY FROM A
TEMPORAL-OCCIPITAL BRANCH OF THE RIGHT PCA, WHICH IS NOT ACCESSIBLE
TO SUPERSELECTIVE MICROCATHETERIZATION.
AFTER COMPLETION OF ENDOVASCULAR SURGERY, ALL CATHETERS WERE REMOVED.
AORTO-ILIAC BIFURCATION DSA WAS INITIALLY PERFORMED AND SUBSEQUENTLY,
THE 7 FR ARTERIAL SHEATH WAS SUTURED INTO THE ADJOINING SKIN FOR USE
AS A CONTINUOUS ARTERIAL PRESSURE LINE.
AORTO-BI-ILIAC DSA- FLUSH INJECTION IN AP PROJECTION SHOWS ABNORMAL
CALIBER OF THE RIGHT COMMON ILIAC,'
MAY BE DUE TO VASOSPASM FORM SHEATH.
BILATERAL ILIO FEMORAL ARTERIAL TREE, WITHOUT EVIDENCE OF STENOSIS OR
OCCLUSION THERE IS NORMAL TRANSIT TIME THERE IS NO EVIDENCE OF
STENOSIS OR DISSECTION WERE BLEEDING FROM THE ARTERIOTOMY SITE. PULL
BACK INTO THE LEFT COMMON ILIAC ARTERY, DIAGNOSTIC DSA VIA HAND FLUSH
INJECTION SHOWS A COMPLETELY NORMAL LEFT ILIOFEMORAL ARTERIAL TREE
WITHOUT EVIDENCE OF STENOSIS, THROMBUS FORMATION OR DISSECTION. THE
ARTERIOTOMY SITE IS ABOVE THE COMMON FEMORAL ARTERY BIFURCATION AND
BELOW THE INGUINAL LIGAMENT. AN 8-FRENCH ANGIO-SEAL ARTERIOTOMY
CLOSURE KIT WAS USED FOR PERCUTANEOUS CLOSURE OF THE ARTERIOTOMY.
IMMEDIATE HEMOSTASIS WAS ATTAINED.
SUMMARY/IMPRESSION-
At first I have Coded it as follow:
61626
36217
75894,26
75898,26
75685,26
Then I asked a co-worker and he came out with a diferent set as follow:
61624
36217
36218,59 x 2
75898,26 x 2
75894,26
75685,26
75774,26,59 x 3
Here is the report and I am so sorry for the Caps. it was extracted from a program that won't allow me to change it
. Thanks for your time and assitance. Report:
VESSELS INJECTED-
RIGHT VERTEBRAL ARTERY,
SUPERSELECTIVE RIGHT P3-PCA, PARIETAL-OCCIPITAL (PO) DIVISION
SUPERSELECTIVE RIGHT P4-PCA, PARIETAL-OCCIPITAL (TO) DIVISION
SUPERSELECTIVE RIGHT P4-PCA X 2
ABDOMINAL AORTA
OPERATIONS/PROCEDURES- THE PROCEDURES, RISKS (INCLUDING STROKE,
DEATH, BLEEDING, COMA, DAMAGE TO BLOOD VESSELS, INFECTION, AND
ADVERSE REACTION TO MEDICATIONS), BENEFITS, AND ALTERNATIVES WERE
DISCUSSED WITH THE PATIENT AND HER FAMILY, IN WHICH ALL QUESTIONS
WERE ANSWERED AND INFORMED CONSENT WAS OBTAINED. THE PATIENT WAS
BROUGHT INTO THE NEURO-INTERVENTIONAL SUITE AND PLACED ON THE
FLUORO/DSA TABLE IN A SUPINE POSITION. A PROCEDURAL TIMEOUT WAS TAKEN
TO VERIFY THE CORRECT PATIENT AND INTERVENTION. BOTH GROINS WERE
PREPPED AND DRAPED IN THE USUAL STERILE FASHION.
THE RIGHT COMMON FEMORAL ARTERY WAS THEN ACCESSED VIA A MODIFICATION
OF THE SELDINGER TECHNIQUE USING SINGLE WALL PUNCTURE TECHNIQUE WITH
AN 18G SINGLEWALL NEEDLE. PULSATILE ARTERIALIZED FLOW WAS OBSERVED,
IN WHICH A GUIDEWIRE WAS THEN INSERTED AND POSITIONED INTO THE AORTA
UNDER FLUOROSCOPIC GUIDANCE. A #7 FRENCH 23 CENTIMETER SHEATH WAS
SUBSEQUENTLY COAXIALLY PLACED OVER A GUIDEWIRE THROUGH THE RIGHT CFA
ARTERIOTOMY AND CONNECTED TO A PRESSURIZED CONTINUOUS HEPARINIZED
NORMAL INFUSION.
A #6-FRENCH 070 NEURON GUIDING CATHETER/# 5-FRENCH NEURON SELECT
BERENSTEIN COMBINATION WAS ADVANCED OVER A 0.035" TERUMO GLIDEWIRE
INTO THE ASCENDING AORTA, AND THEN MANIPULATED SERIALLY INTO THE
RIGHT SUBCLAVIAN AND EVENTUALLY DISTAL RIGHT VERTEBRAL ARTERY UNDER
DSA SUBTRACTED FLUOROSCOPIC GUIDANCE FOR SELECTIVE CATHETER DSA AS
FOLLOWS-
THE RIGHT VERTEBRAL ARTERY WAS THEN SELECTIVELY CATHETERIZED IN WHICH
BIPLANE CEREBRAL ANGIOGRAPHY WAS PERFORMED WITH MULTIPLANAR VIEWS
OBTAINED.
FINDINGS ON SELECTIVE CATHETER DSA-
CEREBRAL ANGIOGRAPHY FROM RIGHT VERTEBRAL ARTERY CEREBRAL ANGIOGRAM
(MULTIPLANAR VIEWS)- THE CERVICAL PORTIONS OF THE RIGHT VERTEBRAL
ARTERY ARE OF NORMAL COURSE AND CALIBER. THERE IS NO REFLUX OF
CONTRAST INTO THE CONTRALATERAL LEFT VERTEBRAL ARTERY. THE BASILAR
ARTERY IS MODERATELY ECTATIC BUT NORMAL CALIBER. NORMAL RIGHT PICA
DISTRIBUTION. BILATERAL SUPERIOR CEREBELLAR ARTERIES ARE OF NORMAL
COURSE AND CALIBER. AGAIN NOTED IS A MEDIUM-SIZE BRAIN AVM SITUATED
WITHIN THE RIGHT OCCIPITAL LOBE. THE DISTAL PCA SUPPLY APPEARS TO
ARISE FROM A MAJOR (PRIMARY) TEMPORAL OCCIPITAL BRANCH WHICH GIVES
OFF TO PRINCIPAL FEEDING SUBPEDICLES (SUPERIOR AND INFERIOR). THE
DISTAL TERRITORY AND CORRESPONDING NIDAL COMPARTMENT FROM THE
PREVIOUSLY DESCRIBED MINOR TEMPORAL-OCCIPITAL BRANCH TO THE AVM IS
OCCLUDED. THE AVM SHOWS EVIDENCE OF CONGESTIVE VENOUS DRAINAGE AND
VENOUS ANEURYSM FORMATION. THERE ARE AT LEAST TWO INTRA-NIDAL
ANEURYSMS AS NOTED EARLIER. THE AVM NIDUS MEASURES APPROXIMATELY 2
CENTIMETERS IN GREATEST DIMENSION.
NEURO-ENDOVASCULAR SURGICAL PROCEDURES-
1. SUPERSELECTIVE ENDOVASCULAR SURGICAL EXPLORATION OF RIGHT P3-PCA
AND TWO SEPARATE RIGHT P4-PCA FEEDING BRANCHES OF BRAIN AVM
2. ULTRA-SUPERSELECTIVE MICROCATHETERIZATION AND TRANSARTERIAL
EMBOLIZATION USING LIQUID NON-ADHESIVE NIDAL EMBOLIZATION WITH
ETHYLENE VINYL ALCOHOL COPOLYMER (ONYX) OF SUPERIOR COMPARTMENT OF
BAVM VIA TERMINAL FEEDING PEDICLE ARISING FROM P4-PCA
PARIETAL-OCCIPITAL DIVISION.
3. ULTRA-SUPERSELECTIVE MICROCATHETERIZATION AND TRANSARTERIAL
EMBOLIZATION USING LIQUID NON-ADHESIVE NIDAL EMBOLIZATION WITH
ETHYLENE VINYL ALCOHOL COPOLYMER (ONYX) OF INFERIOR COMPARTMENT OF
BAVM VIA TERMINAL FEEDING PEDICLE ARISING FROM P4-PCA
PARIETAL-OCCIPITAL DIVISION.
ENDOVASCULAR SURGICAL EXPLORATION WAS PERFORMED BY SUPERSELECTIVE
MICROCATHETER TECHNIQUE TO DETERMINE THE FAVORABILITY OF THE LESION
FOR ULTRA SUPERSELECTIVE TRANS ARTERIAL EMBOLIZATION. A 1.5-FRENCH
MARATHON MICROCATHETER WITH A .008" MIRAGE MICROGUIDEWIRE WAS
NAVIGATED WITHIN THE INTRACRANIAL RIGHT POSTERIOR CIRCULATION UNDER
FLUOROSCOPIC GUIDANCE AND ROAD MAPPING. THE MICROCATHETER WAS FIRST
PLACED IN THE RIGHT P3-PCA SEGMENT.
SUPERSELECTIVE P3-PCA DSA- BIPLANE DSA SHOWS THE MICROCATHETER TO BE
IN NON-WEDGE POSITION OF THE DISTAL MAIN PCA TRUNK IN WHICH
DOWNSTREAM THERE IS A TORTUOUS DISTAL P4-PCA BRANCH THAT GIVES RISE
TO THE PRIMARY SUPPLY TO THE AVM ARISING FROM THE PARIETAL-OCCIPITAL
DIVISION. THERE APPEAR TO BE FISTULOUS COMPONENTS TO THE AVM AS WELL
AS COMPACT NIDUS. ULTRASUPERSELECTIVE MICROCATHETERIZATION WAS THEN
PERFORMED WITH DSA ROADMAPPING AND CONTINUOUS FLUOROSCOPY OF THE
UPPER TERMINAL P4-PCA FEEDING PEDICLE.
RIGHT P4-PCA FEEDING PEDICLE #1 (USS-DSA#2)- BIPLANE DSA FROM P4
TEMPORAL-OCCIPITAL TERMINAL SUPERIOR DIVISION INJECTIONS SHOW THE
CATHETER TO BE UNDER WEDGE CONDITIONS. THIS SHOWED DELAYED
ARTERIOVENOUS SHUNTING THROUGH A MIXED FISTULOUS AND PLEXIFORM NIDAL
SUPEROMEDIAL COMPARTMENT OF THE AVM. THIS BRANCH PROVIDES A SMALL
PORTION OF SUPPLY TO THE AVM. A NIDAL ANEURYSM IS AGAIN SEEN WITHIN
THIS COMPARTMENT.
ENDOVASCULAR SURGICAL OBLITERATION AVM COMPARTMENT #1- UNDER
CONTINUOUS FLUOROSCOPIC GUIDANCE AND BLANK SUBTRACTED FLUOROSCOPY, A
CONTINUOUS COLUMN OF ONYX 18 WAS VERY SLOWLY, AND INTERMITTENTLY
INJECTED INTO THE AVM NIDUS IN WHICH SIGNIFICANT RETROGRADE REFLUX
INTO THE PRIMARY FEEDING PEDICLE OCCURRED. THIS PERMITTED
SUBSEQUENTLY EXCELLENT FLOW CONTROLLED DISTAL EMBOLIZATION OF THE
TARGETED NIDUS. THE EMBOLIC AGENT SLOWLY PENETRATED WELL INTO THE
TARGETED COMPARTMENT OF THE AVM NIDUS RESULTING IN EXCELLENT
OBLITERATION OF A SIGNIFICANT PORTION OF THE INFERIOR COMPARTMENT THE
AVM. NO NONTARGET DELIVERY OF THE EMBOLIC AGENT WAS NOTED.
CONTROL DSA FROM SELECTIVE RIGHT VERTEBRAL INJECTION- BIPLANE DSA
SHOWS APPROXIMATELY 60% OVERALL NIDAL VOLUME REDUCTION OF THE AVM
WITH PRESERVATION OF THE PRINCIPAL DRAINING VEINS. THERE HAS BEEN
SIGNIFICANT REDUCTION IN OVERALL AV SHUNTING. THE DISTAL PCA
TERRITORIES WITHIN TEMPORAL AND PARIETAL LOBES APPEAR NORMAL, WITHOUT
EVIDENCE OF EMBOLIC OCCLUSION.
ENDOVASCULAR SURGICAL EXPLORATION WAS PERFORMED BY SUPERSELECTIVE
MICROCATHETER TECHNIQUE TO DETERMINE THE FAVORABILITY OF THE LESION
FOR ULTRA SUPERSELECTIVE TRANS ARTERIAL EMBOLIZATION. A 1.5-FRENCH
MARATHON MICROCATHETER WITH A .008" MIRAGE MICROGUIDEWIRE WAS
NAVIGATED WITHIN THE INTRACRANIAL RIGHT POSTERIOR CIRCULATION UNDER
FLUOROSCOPIC GUIDANCE AND ROAD MAPPING. THE MICROCATHETER WAS THEN
PLACED IN THE RIGHT P3-PCA SEGMENT. ULTRASUPERSELECTIVE
MICROCATHETERIZATION WAS THEN PERFORMED WITH DSA ROADMAPPING AND
CONTINUOUS FLUOROSCOPY OF THE LOWER, DOMINANT TERMINAL P4-PCA FEEDING
PEDICLE.
RIGHT P4-PCA FEEDING PEDICLE #2 (USS-DSA#4)- BIPLANE DSA FROM P4
PARIETAL-OCCIPITAL TERMINAL DIVISION INJECTIONS SHOW THE CATHETER TO
BE UNDER NEAR-WEDGE CONDITIONS. THIS SHOWED ARTERIOVENOUS SHUNTING
THROUGH A MIXED FISTULOUS AND PLEXIFORM NIDAL INFEROMEDIAL
COMPARTMENT OF THE AVM. NORMAL CORTICAL BRANCHES WERE NOT VISUALIZED
PROXIMAL TO THE SITE OF AV SHUNTING. NIDAL ANEURYSMS ARE AGAIN SEEN
WITHIN THIS COMPARTMENT.
ENDOVASCULAR SURGICAL OBLITERATION AVM COMPARTMENT #2- UNDER
CONTINUOUS FLUOROSCOPIC GUIDANCE AND BLANK SUBTRACTED FLUOROSCOPY, A
CONTINUOUS COLUMN OF ONYX 16 WAS VERY SLOWLY, AND INTERMITTENTLY
INJECTED INTO THE AVM NIDUS IN WHICH SIGNIFICANT RETROGRADE REFLUX
INTO THE PRIMARY FEEDING PEDICLE OCCURRED. THIS PERMITTED
SUBSEQUENTLY EXCELLENT FLOW CONTROLLED DISTAL EMBOLIZATION OF THE
TARGETED NIDUS. THE EMBOLIC AGENT SLOWLY PENETRATED WELL INTO THE
TARGETED COMPARTMENT OF THE AVM NIDUS RESULTING IN EXCELLENT
OBLITERATION OF A SIGNIFICANT PORTION OF THE INFERIOR COMPARTMENT THE
AVM. NO NONTARGET DELIVERY OF THE EMBOLIC AGENT WAS NOTED.
FINAL CONTROL DSA FROM SELECTIVE RIGHT VERTEBRAL INJECTION- BIPLANE
DSA SHOWS GREATER THAN 95% OVERALL NIDAL VOLUME REDUCTION OF THE AVM
WITH PRESERVATION OF THE PRINCIPAL DRAINING VEINS. THERE HAS BEEN
DRAMATIC REDUCTION IN OVERALL AV SHUNTING. THE DISTAL PCA TERRITORIES
WITHIN TEMPORAL AND PARIETAL LOBES APPEAR NORMAL, WITHOUT EVIDENCE OF
EMBOLIC OCCLUSION. THERE IS EN PASSANT SUPPLY FROM A
TEMPORAL-OCCIPITAL BRANCH OF THE RIGHT PCA, WHICH IS NOT ACCESSIBLE
TO SUPERSELECTIVE MICROCATHETERIZATION.
AFTER COMPLETION OF ENDOVASCULAR SURGERY, ALL CATHETERS WERE REMOVED.
AORTO-ILIAC BIFURCATION DSA WAS INITIALLY PERFORMED AND SUBSEQUENTLY,
THE 7 FR ARTERIAL SHEATH WAS SUTURED INTO THE ADJOINING SKIN FOR USE
AS A CONTINUOUS ARTERIAL PRESSURE LINE.
AORTO-BI-ILIAC DSA- FLUSH INJECTION IN AP PROJECTION SHOWS ABNORMAL
CALIBER OF THE RIGHT COMMON ILIAC,'
MAY BE DUE TO VASOSPASM FORM SHEATH.
BILATERAL ILIO FEMORAL ARTERIAL TREE, WITHOUT EVIDENCE OF STENOSIS OR
OCCLUSION THERE IS NORMAL TRANSIT TIME THERE IS NO EVIDENCE OF
STENOSIS OR DISSECTION WERE BLEEDING FROM THE ARTERIOTOMY SITE. PULL
BACK INTO THE LEFT COMMON ILIAC ARTERY, DIAGNOSTIC DSA VIA HAND FLUSH
INJECTION SHOWS A COMPLETELY NORMAL LEFT ILIOFEMORAL ARTERIAL TREE
WITHOUT EVIDENCE OF STENOSIS, THROMBUS FORMATION OR DISSECTION. THE
ARTERIOTOMY SITE IS ABOVE THE COMMON FEMORAL ARTERY BIFURCATION AND
BELOW THE INGUINAL LIGAMENT. AN 8-FRENCH ANGIO-SEAL ARTERIOTOMY
CLOSURE KIT WAS USED FOR PERCUTANEOUS CLOSURE OF THE ARTERIOTOMY.
IMMEDIATE HEMOSTASIS WAS ATTAINED.
SUMMARY/IMPRESSION-