Transcatheter therapy neuro?

chembree

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I posted this in another forum but wanted to see if anyone here could offer any guidance?

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CLINICAL HISTORY: Nonsmall cell lung carcinoma metastatic to bones.
Status post kyphoplasty T11 and L1 for pathologic compression fractures.
Impending suspected fractures of T12 and L2, given the degree of
neoplastic burden currently. Extensive bony metastatic disease to the
right sacrum and right iliac bone. Severe intractable right hip and
right sacral pain.

PROCEDURE: Informed consent was obtained. A preprocedure pulse was
performed.

MAC anesthesia was provided by anesthesia department.

The right groin was prepped and draped in the usual sterile fashion. 1%
lidocaine was used as a local anesthetic.

Ultrasound guided puncture of the right common femoral artery was
performed with an 18-gauge arterial needle followed by a guidewire over
which the with placement of a 5 French angiographic sheath. There is
ultrasound documentation of needle entry within the right common femoral
artery with images sent to PACs.

Pigtail catheter was initially utilized for abdominal aortogram placed
over a guidewire. The pigtail catheter was retracted to the caudal aorta
and pelvic arteriogram was also performed. After pelvic aortogram, there
was exchanged of the pigtail catheter for a 5 French Mickelson catheter
over a guidewire selective lumbar artery arteriograms were performed at
the left L2 level using a Mickelson catheter and subsequently at the
right T12 level using Mickelson catheter. It was through these catheters
with selective catheterization of initially left L2 and then
subsequently right T12 that embolization was performed using 1 mL
aliquots 500 to 700 micron sized embospheres delivered in efforts to
provide embolization to neovascularity identified with tumor staining
involving these 2 vertebral bodies. In addition gelfoam slurries were
delivered in 1 mL aliquots at these levels to help to provide near
angiographic stasis of these vessels.

Next, the right internal iliac artery was selected catheterized and a
Renegade 2.2 French microcatheter was utilized to selectively
catheterize the medial branch off the posterior division of the right
internal iliac artery. It was this particular branch where there was
demonstrated staining of neovascularity identified within the lateral
right sacrum. Following embolization with the 500 to 700 micron sized
embospheres and the use of Gelfoam slurry to accomplish near
angiographic stasis, there was subselective catheterization using
microcatheter into a branch of the posterior division internal iliac
artery laterally avoiding the gluteal branches at which point through
the microcatheter, embolization was performed in these tertiary vessels
in efforts to embolize neovascularity with tumor staining to involve the
supraacetabular aspect of the right iliac bone. With delivery of the 500
- 700 micron sized embospheres in 1 mL aliquots along with Gelfoam
slurry there was near angiographic stasis achieved.

Catheters were withdrawn. Hemostasis was achieved at the right groin
puncture site with no change in the right dorsalis pedis pulse compared
to preprocedure poles. There were no immediate complications.

Total contrast load was 275 mL of Isovue-370. Total embolic load was
one vial of 500 to 700 micron sized embospheres.

Fluoroscopic time 40.4 minutes.

FINDINGS: Abdominal aortogram: The aorta is nonaneurysmal. There is
single bilateral renal arteries. There is filling of the celiac axis and
SMA. The IMA is not identified. There is tight flow-limiting stenosis to
involve the right common iliac artery. The this stenosis was not
treated.

Selective left L2 lumbar arteriogram: There is rapid flow into the
lumbar muscular branch however there is a medial branch seen to provide
neovascularity and tumor staining within the left aspect of the L2
vertebral body.

Followup embolization selective left L2 lumbar arteriogram: There is
sluggish transit of contrast as expected postembolization. The staining
of the left sided tumor blush is near completely resolved
postembolization.

Selective right T12 lumbar arteriogram: There is rapid flow into the
intercostal branch however there is a medial branch seen to provide
neovascularity in tumor staining within the right aspect of the T12
vertebral body.

Followup embolization selective right T12 lumbar arteriogram: There is
sluggish transit of contrast as expected postembolization. The staining
of the right-sided tumor blush is near completely resolved
postembolization.

Selective right posterior division internal iliac artery lateral sacral
branch arteriogram: There is tumor staining to involve the right medial
sacrum.

Followup embolization posterior division internal iliac artery lateral
sacral branch arteriogram: There is sluggish transit of contrast as
expected postembolization.

Selective right posterior division internal iliac artery superior
gluteal parasitized osseous branch arteriogram: There is 2 sites of
large tumor staining to involve the right supra acetabular aspect of the
iliac bone representing the neovascularity of metastatic disease.

Followup embolization selective right posterior division internal iliac
artery superior gluteal parasitized osseous branch arteriogram: There is
sluggish transit of contrast as expected postembolization. There is some
inadvertent sluggish flow within muscular gluteal branches.

CONCLUSION: Supraselective tumor embolization involving 4 sites, 2 of
which are vertebral L2 and T12 and the third to involve the medial right
sacrum and the fourth to involve the super acetabular right iliac bone.

The patient was recovered later that day and discharged home. Close
clinical followup is planned with Dr. Jones. I believe the patient would
also benefit from concurrent radiation therapy.

Thank you for referring patient to Interventional Radiology for their
procedure and allowing me to participate with you in their care

I need help with this report! I have some of the codes listed below. Any thoughts?

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Ultrasound guided puncture- vessel patency not documented
75625- abdominal aortogram
75716- caudal aorta and pelvic arteriogram
36245- selective catheterization of initially left L2
36245- T12 level
75705- lumbar artery arteriogram
75705 -T12 lumbar arterogram
61624- T12 that embolization
75894- T12 that embolization S&I
36247- tertiary vessels of the the right internal iliac
36248- posterior division internal iliac artery lateral sacral branch
75898- Followup embolization selective right T12 lumbar arteriogram
75774- posterior division internal iliac artery lateral sacral branch
75774- posterior division internal iliac artery superior gluteal parasitized

Can I charge the 75898 more than once? My CSI book says, For neurologic embolization more than one unit of 75898 may be reported.
 
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