I agree.Can anyone please confirm my codes for the below procedure,
Using real time ultrasound guidance, access was
obtained into the a peripheral right portal vein branch using a 21
gauge Chiba needle. A 0.018 inch guide wire was advanced through
the needle into the portal vein. The needle was removed and
exchange for a Neff coaxial dilator. A seven French vascular
sheath was then placed extending into the portal vein. Portal
venography was performed. A 6 French MPA guiding catheter and a
coaxially.-placed 4 French Berenstein catheter were advanced
through the sheath and guided to the site of occlusion. A
rock-hard occlusion of the main portal was then crossed using a
hydrophilic guidewire and the catheter advanced into the superior
mesenteric vein. The catheter was then exchanged for a 5 French
sizing pigtail catheter which was positioned within the midportion
of the superior mesenteric vein. A superior mesenteric/portal
venogram was performed.
After exchanging over a stiff guide wire, a 12 mm x 60 mm
self-expanding Smart stent was deployed across the main portal
vein occlusion extending into the right portal vein. The stent
was dilated using a 10 mm x 4 cm angioplasty balloon. Repeat
portal venography was performed. A 6 French Possis mechanical
thrombectomy device was then deployed within the main and right
portal vein. Approximately 200 cc of fluid was aspirated. Repeat
venography was performed. A multi-sidehole infusion catheter with
a 10 cm long infusion length was then deployed extending from the
upper superior mesenteric vein through the right portal vein. The
right portal veins was then laced with 4 cc of alteplase. The
patient was started on continuous infusion of alteplase through
the infusion catheter at a total rate of 0.5 mg per hour. The
catheter and sheath were sutured into place and a sterile dressing
applied to the site.
Findings: Portal venography demonstrates patency of the superior
mesenteric and splenic veins. Abrupt occlusion of the main portal
vein beyond the junction of the superior mesenteric and splenic
veins is noted. The occlusion extends for approximately 2.5-3 cm
in length. Outflow is via tortuous, enlarged collateral vessels
within the upper abdomen. A splenorenal shunt is identified.
Partially obstructing intraluminal thrombus is identified within
the right and left portal veins as well as in several right portal
vein branches. The stent was deployed extending from junction of
the splenic and superior mesenteric veins, across the main portal
vein and extending into the right portal vein. Following stent
deployment and dilatation, poor flow is identified within the
distal branches secondary to intraluminal thrombus. Mechanical
thrombectomy using a 6 French Possis thrombectomy device was then
performed with restoration of flow within the portal veins.
However, intraluminal thrombosis was still identified within
several branches. The patient was started on continuous infusion
of alteplase into the portal vein as described above.
Conclusion: Portal venogram demonstrating 2.5-3 cm long occlusion of the main
portal from its origin and extending to the right and left portal
veins. Partially-obstructing thrombus is identified within the
right and left portal veins, as identified on previous CT scan of
August 3. Outflow from the superior mesenteric and splenic veins
is via enlarged collateral vessels within the upper abdomen. A
prominent splenorenal shunt is identified.
Successful deployment and dilatation of 12 mm x 6 cm
self-expanding Smart stent across the portal venous occlusion
extending into the right portal with good cosmetic result as
Mechanical thrombectomy of portal vein thrombus was performed
using a 6 French Possis thrombectomy device as described above.
The patient was started on continuous thrombolytic infusion via
multi-sidehole infusion catheter deployed across the main and
right portal veins. The patient is to continue infusion overnight
while being observed in the intensive care unit and is to return
tomorrow for followup examination.
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