Can anyone suggest codes for this treatment My brain is melting:

SERVICES PROVIDED:
1. Inferior vena cavogram. 2. Right leg venogram. 3. Initiation of thrombolytic therapy using catheter- directed low-dose TPA. 4. Intravenous moderate sedation. 5. Ultrasound guidance for venous access.


CATHETER POSITIONING:
1.

From a right internal jugular vein approach, a 5-

French pigtail catheter was placed into the right common iliac vein. 2.

A 5-French multiple sidehole infusion catheter was advanced fluoroscopically over a wire into the right popliteal vein.

The procedure was explained in detail to the patient. Potential risks, benefits, and alternate therapies were discussed.

All questions were answered and informed consent was obtained.

The patient was given IV moderate sedation throughout the procedure using IV Versed and fentanyl. The patient was monitored with automatic blood pressure cuff measurement, EKG, and pulse oximetry throughout the procedure.

Medications were administered by an RN under the direct supervision of the IR attending.

The patient's leg was examined with ultrasound. The patient's right neck was examined with ultrasound showing patency of the right internal jugular vein. The patient's right arm was examined with ultrasound showing patency of the right basilic vein. The patient's right arm was sterilely scrubbed, prepped and draped in the standard fashion. Local anesthetic was applied using 2% Xylocaine. Using ultrasound guidance and a micropuncture needle, access was gained into the right basilic vein. Ultrasound was used to visualize the needle entering into the lumen of the vessel. Percutaneous access was dilated to accept a 5-French double lumen PICC line which was negotiated fluoroscopically into the superior vena cava. Tip of the catheter was left in the SVC near the SVC/right atrial junction. Both lumens of the catheter were then tested and flushed with dilute heparinized saline.

The catheter was placed for blood draws and administration of medications during thrombolytic therapy.

The patient's right neck was examined with ultrasound showing patency of the right internal jugular vein.

The patient's right neck, shoulder, and chest were sterilely

scrubbed, prepped and draped in the standard fashion. Local anesthetic was applied using 2% Xylocaine. Using ultrasound guidance and a micropuncture needle, access was gained into the right internal jugular vein. Ultrasound was used to visualize the needle entering into the lumen of the vessel. The percutaneous access was dilated to accept a 5-French introducer sheath through which a 5- French pigtail catheter was placed. The pigtail catheter was guided fluoroscopically over a wire through the right atrium and into the inferior vena cava. The pigtail catheter was positioned within the right common iliac vein and inferior vena cavogram was performed.

The vena cavogram was performed using gadolinium as contrast agent as the patient was allergic to iodine contrast.

The pigtail catheter was exchanged over a wire for a 5- French angled catheter. The 5-French introducer sheath was exchanged over the wire for a 6-French introducer sheath which was guided fluoroscopically into the right iliac vein. Using the angled catheter and Glidewire, access was gained down the thrombosed deep venous system of the right leg through the femoral vein and to the popliteal vein. The 5-French angled catheter was removed and replaced with a 5-French infusion catheter with 30 cm of infusion length. The multiple sidehole infusion catheter was positioned over the wire in the femoral vein and popliteal vein. Small amount of contrast was injected documenting thrombosis of the deep venous system of the right leg. Thrombolytic therapy was then restarted at 0.48 mg an hour through the infusion catheter.

Catheter and sheath were then securely draped and the patient was transferred to the ICU for overnight observation.


FINDINGS:
Inferior vena cavogram shows patency of the IVC and right common iliac vein. There is thrombus extending from the deep venous system of the right leg into the right external iliac vein.

A multiple sidehole infusion catheter was positioned to optimize delivery of TPA to the thrombus within the right popliteal femoral vein common femoral and iliac vein.

IMPRESSION 1.

EXTENSIVE THROMBOSIS OF THE DEEP VENOUS SYSTEM OF THE RIGHT LOWER EXTREMITY FROM THE POPLITEAL UP TO AND INCLUDING THE EXTERNAL ILIAC VEIN.

2.

WIDELY PATENT IVC AND RIGHT COMMON ILIAC VEIN.

3.

THROMBOLYTIC THERAPY INITIATED THROUGH A MULTIPLE SIDEHOLE POSITIONED TO OPTIMIZE DELIVERY OF TPA TO THE ACUTE THROMBOSIS WITHIN THE RIGHT LOWER EXTREMITY.




SERVICES PROVIDED 1. Right leg venogram during thrombolytic therapy. 2. Catheter exchanged during thrombolytic therapy. 3. Intravenous moderate sedation. 4. Mechanical thrombectomy using AngioJet right leg deep vein thrombosis.

Following 24 hours of thrombolytic therapy, using catheter-directed low dose TPA for extensive right lower extremity DVT, a repeat venogram was preformed through the preexisting catheters. The catheter was removed over a 0.035 wire and replaced with a 6-French AngioJet catheter. The extensive DVT within the right popliteal femoral vein and common femoral vein was mechanically declotted using the AngioJet catheter. The catheter was removed over the wire and replaced with a 5-French multiple sidehole infusion catheter which was positioned within the distal femoral vein and popliteal vein to optimize delivery of TPA to residual clot. Attempts were made unsuccessfully to gain access using a wire into the posterior tibial vein from above.

The right ankle was sterilely scrubbed, prepped and draped in the standard fashion. Local anesthetic was applied using 2% Xylocaine. Using ultrasound guidance and a micropuncture needle, attempts were made unsuccessfully to gain access into the thrombosed distal right posterior tibial vein at the level of the ankle. Attempts were made with application of a tourniquet below the knee joint. Further attempts were, therefore, abandoned.

FINDINGS:
Following 24 hours of thrombolytic therapy using catheter-directed low dose TPA, a repeat venogram of the right lower extremity shows marked improvement in lysis of the extensive right leg DVT. The persistent thrombus was noted within the distal femoral vein, proximal femoral vein and the popliteal vein. Stagnant flow was also noted.

Following mechanical thrombectomy of the extensive DVT with the AngioJet catheter, there was some improvement in lysis of the clot within the popliteal and femoral vein of the right leg.

IMPRESSION 1. SIGNIFICANT IMPROVEMENT IN LYSIS OF THE EXTENSIVE

RIGHT LEG DVT FOLLOWING 24 HOURS OF THROMBOLYTIC THERAPY USING CATHETER-DIRECTED LOW DOSE TPA AND FOLLOWING MECHANICAL THROMBECTOMY WITH THE ANGIOJET CATHETER.

2. FAILED ATTEMPTS TO GAIN ACCESS INTO THE THROMBOSED RIGHT POSTERIOR TIBIA VEIN.

3. CATHETER EXCHANGE AND REPOSITIONING TO OPTIMIZE DELIVERY OF TPA TO RESIDUAL THROMBUS WITHIN THE POPLITEAL AND FEMORAL VEIN.



SERVICES PROVIDED
1. Left leg venogram during thrombolytic therapy.
2. Catheter exchanged during thrombolytic therapy.
3. Placement of a catheter into the right posterior
tibial vein.

Following 48 hours of thrombolytic therapy using
catheter-directed low dose TPA, repeat venogram was
preformed through the preexisting catheter positioned
within the right popliteal and femoral vein. Contrast used
was gadolinium due to the patient's IODINE DYE ALLERGY. a

total of 15 mL of gadolinium was used throughout the
entire procedure.

The 5-French multiside-hole infusion catheter was
exchanged over a wire and replaced with a new catheter
positioned within the popliteal vein. Thrombolytic therapy
was restarted through the catheter.

The right ankle was sterilely scrubbed, prepped and
draped in the standard fashion. Local anesthetic was
applied using 2% Xylocaine. Using ultrasound guidance
and a micropuncture needle, access was gained into the
right posterior tibial vein. Ultrasound was used to
visualize the needle entering into the lumen of the
vessel. Percutaneous access was then dilated to accept a 5-
French catheter. Thrombolytic therapy was then infused
directly into the posterior tibial vein above the right
ankle.

A total of 0.48 mg of TPA/hour was administered split
between dose given in the posterior tibial vein and
multiple sidehole infusion catheter within the popliteal
and femoral vein.

The dressings were reapplied and the patient was then
transferred back to the ICU for overnight observation.

FINDINGS: A repeat venogram of the right leg shows some
improvement in lysis of the extensive DVT within the
right popliteal and femoral vein. Attempts were made
unsuccessfully to gain access into the tibial vein from
the popliteal vein approach. Multiple sidehole infusion was,
therefore, exchanged and repositioned to optimize
delivery of TPA to residual clot within the distal
femoral vein and popliteal vein.


Access was gained into the patent segment of the right
distal posterior tibial vein. A wire was passed from the
access site up into the popliteal vein fluoroscopically.
Limited venogram was performed showing segmental
occlusion of the posterior tibial vein and tibial veins.

IMPRESSION
1. ACCESS GAINED INTO THE POSTERIOR TIBIAL VEIN OF THE
RIGHT LEG TO DELIVER THROMBOLYTIC THERAPY TO THE TIBIAL
VEINS OF THE CALF.

2. INTERVAL IMPROVEMENT IN LYSIS OF THE EXTENSIVE RIGHT
LEG DVT FOLLOWING AN ADDITIONAL 24 HOURS OF THROMBOLYTIC
THERAPY.

3. CATHETER EXCHANGE AND REPOSITIONING TO OPTIMIZE
DELIVERY OF TPA TO THE RESIDUAL CLOT WITHIN THE POPLITEAL
AND DISTAL FEMORAL VEIN FROM A RIGHT IJ APPROACH.



SERVICES PROVIDED:
Right leg venogram during thrombolytic therapy.

Following an additional 24 hours of thrombolytic therapy using catheter-directed low dose TPA, repeat venogram was preformed through the right posterior tibial vein catheter as well as the right femoral vein multiple sidehole catheter. Gadolinium was the contrast agent used due to the patient's IODINE CONTRAST DYE ALLERGY.

The thrombolytic therapy was thereafter discontinued. The patient was transferred to the ICU where the venous sheath and right vein catheter were removed 2 hours after discontinuation of heparin and TPA.

FINDINGS:
Repeat venogram of the right calf shows segmental occlusion of the deep venous system within the calf. Segments of the posterior tibial vein were patent up to the popliteal vein. Numerous collaterals within the calf were identified. These findings were consistent with acute on chronic deep venous thrombosis involving the below the knee tibial vessels.

Repeat venogram of the femoral vein shows patency of the popliteal femoral vein common femoral vein.

Clinically, the patient's calf and thigh were markedly less tense and less swollen than was first presentation.

IMPRESSION 1. SUCCESS THROMBOLYSIS OF ACUTE EXTENSIVE DEEP VEIN THROMBOSIS FROM THE POPLITEAL VEIN UP TO AND INCLUDING THROMBUS WITHIN THE EXTERNAL ILIAC VEIN.

2. ACUTE ON CHRONIC DEEP VEIN THROMBOSIS INVOLVING THE DEEP VENOUS SYSTEM WITHIN THE CALF WITH MINOR IMPROVEMENT IN FLOW FOLLOWING CATHETER-DIRECTED LYSIS.


Thanks