Wiki Vascular Coding Question

conleyclan

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Good Morning,

This patient was having a transcatheter aortic valve replacement. They had problems and they had to place extra stents for dissection of the vertebral/subclavian artery. Can someone assist me in coding this report. I would use the 33363 for the TAVR, but after that I am not sure how to code the stent placement once the dissection was found. Thanks.

PROCEDURES PERFORMED: Transcatheter aortic valve replacement (23-mm
Medtronic Evolut), left subclavian arterial cutdown with primary repair,
left subclavian arterial stenting (6 x 60 mm Cordis bare-metal stent, 6 x
40 mm Cordis bare-metal stent), vertebral arterial stent grafting (3.5 x 19
mm Jomed covered stent), thoracic aortogram, left subclavian arteriogram
and left vertebral arteriogram with radiologic supervision and
interpretation, right common femoral arterial sheath placement
percutaneously, temporary right ventricular pacing lead via right internal
jugular vein, left vertebral arterial dissection and disruption and left
subclavian arterial dissection..
BRIEF HISTORY: The patient is an 87-year-old female with a history of
severe symptomatic aortic stenosis who was evaluated by our
Multidisciplinary Valve team and deemed to be at extreme risk for
conventional surgical aortic valve replacement, but a reasonable candidate
for transcatheter aortic valve replacement. She was vasculopath with very
small and diseased iliofemoral arteries precluding iliofemoral access. She
also had a small caliber left subclavian artery, but deemed to be adequate
size to proceed with left subclavian access.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. A central
line and radial arterial line were placed by the Anesthesia team for
intraoperative monitoring. Transesophageal echocardiogram was performed
and confirmed the above-noted findings of severe aortic stenosis. There
was additional mitral regurgitation noted.
The patient was prepped and draped in the usual sterile fashion from the
ears to the knees. The right internal jugular vein was accessed
percutaneously using a Seldinger technique, a 6-French sheath was placed
through which a temporary right ventricular pacing lead was advanced into
the RV apex for use for rapid ventricular pacing. Next, the right common
femoral artery was accessed percutaneously using a Seldinger technique, a
5-French destination sheath was advanced into the descending thoracic
aorta. Next, a 3 cm transverse incision was made below and lateral to the
angle of the left clavicle. The pectoralis fascia was incised
transversely. The pectoralis muscle fibers retracted. The pectoralis
minor retracted inferiorly and then the left subclavian artery
circumferentially dissected out with vessel loops placed proximally and
distally. We then heparinized the patient to ACT over 300 seconds and
introduced an 18-gauge needle into the left subclavian artery under direct
vision. We then advanced the guidewire into the ascending aorta. A
pigtail catheter was advanced via the destination sheath from the right
groin and positioned in the nadir of the noncoronary sinus. A thoracic
aortogram was performed to identify the optimal orthogonal plane relative
to the aortic annulus fluoroscopically. Next, a 5-French sheath was placed
over the guidewire in the left subclavian artery and an AL1 catheter was
advanced over the guidewire down just above the stenotic aortic valve.
Through that AL1 catheter, we then advanced a straight floppy guidewire
across the stenotic aortic valve. Once in the LV, it was exchanged for a
pigtail catheter and we obtained simultaneous pressures of the ascending
aorta and LV confirming a high gradient across the stenotic aortic valve.
Next, the pigtail catheter in the LV was exchanged for an Amplatz Super
Stiff guidewire tailored at its tip into a pigtail shape. This served as
her anchoring wire over which a 23 mm Medtronic CoreValve was advanced with
its inline sheath into the ascending aorta. We then traversed the stenotic
aortic valve and positioned the Medtronic Evolut valve at the level of the
annulus. We then began a slow deployment of the Evolut valve and performed
a second arteriogram confirming position of the CoreValve relative to the
aortic annulus. We then proceeded to 100% deployment and released the
Evolut valve. We then withdrew the delivery system and in doing so, the
Amplatz guidewire had retracted outside of the left ventricle and
therefore, we removed the delivery system from the left subclavian artery.
We then placed a 14-French sheath over the Amplatz guidewire and removed
the Amplatz and attempted to recross the aortic valve; however, we were
unable to position the guidewire appropriately and therefore, we exchanged
the guidewire for a Glidewire and then made an attempt at passing the
14-French dilator and sheath over that guidewire. However, with
advancement of that sheath, the sheath appeared to enter the vertebral
ostium off the left subclavian and with advancement caused the proximal
left vertebral arterial dissection and there was some small amount of
localized extravasation. This raised concerns that the localized vertebral
dissection will extend proximally involving the left subclavian and
therefore, we made immediate plans to stent the left vertebral artery.
This was achieved via the right common femoral arterial destination sheath.
This was exchanged over a guidewire for a 6-French sheath and the 6-French
guide catheter was advanced up into the left subclavian artery through that
guide catheter, we then advanced a Whisper wire up through the vertebral
ostium and into the left vertebral. Within the true lumen and advanced the
Whisper wire up into the neck well beyond the area of vertebral injury.
Over that Whisper wire, we then advanced a 2 x 12 mm noncompliant balloon
and balloon dilated the area of localized dissection. We then removed that
balloon tip catheter and advanced a 3.5 x 19 mm Jomed covered stent across
the area of vertebral injury. We then deployed that Jomed stent nicely,
got complete coverage of the area of injury. Of note, subclavian
arteriography was done prior to deployment of either the previous
pre-dilatation balloon or the Jomed stent as well as following deployment
of the Jomed stent and in doing so, we confirmed no residual extravasation.
We did note that there was a localized area of retrograde dissection into
the left subclavian and consequently over the guidewire into the left
subclavian in the retrograde fashion, we advanced an 8 x 60 mm Cordis
bare-metal stent across the proximal subclavian and across the vertebral
arterial mammary arterial and thyrocervical trunk. The self-expanding
stent was deployed without incident and arteriography demonstrated complete
apposition of the localized dissection flap against the native subclavian
wall with resolution of the dissection. We then removed the sheath from
the left subclavian artery and repaired that vessel primarily with running
6-0 Prolene suture. We then performed a left subclavian arteriogram and
this demonstrated wide patency of the left vertebral artery. No
extravasation and resolution of dissection of left subclavian artery, but
it also showed mild stenosis at the anastomotic site of the distal left
subclavian and therefore, we elected to place a second subclavian arterial
stent to treat that localized stenosis. This was done again via an
antegrade fashion through the destination sheath from the right common
femoral artery. A 6 x 40 mm Cordis self-expanding stent was advanced over
a guide catheter into the distal left subclavian across the anastomotic
site. Once in position, it was deployed and we got excellent expansion
with resolution of the stenosis. We then performed a final arteriogram
confirmed wide patency of the entire left subclavian with excellent inflow
to the vertebral and no extravasation. At this point, we terminated the
procedure, excepting the mild-to-moderate perivalvular leak as there was no
adequate access to dilate the valve further. The Evolut was expanded
completely and it was in excellent position. The heparin was then reversed
with IV protamine. The right common femoral arterial sheath was removed
and direct pressure held to hemostasis. The left subclavian access
incision was then closed in layers with running absorbable sutures.
 
I wouldn't bill for either of those stents. The first one was to correct a dissection caused by the surgeon and the second was prophylactic to prevent any further damage. These kind of situations fall under an ethical boundary: any time the physician/surgeon causes damage I do not bill for it.
 
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