Venous Intervention


Marion, IA
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Can anyone help with this peripheral procedure?

1. Left lower extremity venogram.
2. Percutaneous transluminal angioplasty and stent placement to left greater saphenous vein.
3. Ultrasound guidance diagnosis AV fistula.

HISTORY: The patient is a 68-year-old white male with a history of recurrent DVTs, on warfarin therapy and a history of prior trauma to the chest and extremities, who presents with left groin arteriovenous fistula. The patient has had progressive left lower extremity edema and discomfort. Due to persistence of symptoms, he is referred for percutaneous intervention.

TECHNIQUE: Informed consent was obtained. The patient was brought to the catheterization labs. He received systemic Versed and fentanyl as well as topical lidocaine. Left leg was sterilely prepped and draped. Topical lidocaine applied. Using ultrasound guidance, the left greater saphenous vein was accessed using micropuncture needle. Initially a 4-French and finally a 6-French sheath were positioned using modified Seldinger technique. A 0.018 inch angled glide wire was then advanced into the IVC and ultrasound performed to confirm left common femoral to greater saphenous vein fistula. It is a fairly large tortuous fistula with significant reflux and increased velocity into the left greater saphenous vein. There was significant aneurysmal dilatation of the proximal segment. No flow was noted in the deep vein. There appeared to be an appropriate neck at the junction for percutaneous stent placement. The patient then received systemic heparin and a 6 x 22 mm Atrium covered stent was introduced, carefully positioned at the origin of the greater saphenous vein careful not to extend into the deep saphenous vein and deployed at 10 atmospheres for 60 seconds. This was then postdilated using 8 x 20 Biotronik Passeo-35 stent at up to 16 atmospheres for 10 minutes. Repeat angiography continued to show some mild turbulence in the venous system as well as in the AV fistula. We post dilated again using a 10 x 20 Biotronik Passeo-35 balloon at up to 16 atmospheres for 10 minutes. This was slowly increased and decreased to confirm occlusion of the AV fistula. Manual pressure was also applied to supplement the balloon. Finally after confirmation of no turbulent flow in the vein for an extended period time, balloon and manual pressure were discontinued. Ultrasound showed mild turbulence in the proximal segment of the AV fistula near the common femoral artery where the vessel appeared to have been damaged. However, the tortuous segment had significant diminished flow and there is no increased velocity in the venous system. Venography was then performed using manual injection of contrast to the sheath showing an excellent result with full apposition of the stent with vessel wall. We were away from the deep saphenous vein. There was appropriate reflux and the deep saphenous vein collaterals were noted with no negative contrast suggests continuing arterial venous flow. This was deemed an acceptable result. ACT drifted down to normal. The venous sheath was retracted. Manual pressure applied until hemostasis was achieved. The patient tolerated the procedure well and was transferred to the floor in a stable condition. A total of 10 mL of contrast was utilized.

FINAL RESULTS: Successful percutaneous intervention, placement of covered stent to the origin of the left greater saphenous vein for occlusion of the AV fistula using a 6 x 22 mm Atrium covered stent postdilated to 10 mm.

ASSESSMENT AND PLAN: The patient is a 68-year-old gentleman with progressive edema and pain in left lower extremity due to large AV fistula and significant reflux. He has undergone placement of covered stent to protect the vein and hopefully help facilitate occlusion of the shunt. We will repeat ultrasound in several weeks should he continue to have shunting and increased velocities and turbulence in the vein, consideration may now be given towards percutaneous intervention to the fistula as the vein is protected.

I think the coding should be 37238, 76937-26 and I'm not sure if I need to code 36010 or 36005, 75820-26?

Mobile, Alabama
Best answers
Good Morning:
In response to your question, I would code 37238 and 76937. The physician does not show a "separate" procedure for the injection of the venography. Therefore, you cannot code this. If the physician had performed the venography for an additional anatomical site, you could have also coded the 36005. This is the hierarchy and would be inclusive of the 37238.

Hope this helps :)