# Venous Intervention



## leahlhaynie (Apr 4, 2011)

This is the first time one of our doctors has done a venous intervention, and I would appreciate any help that could be provided. Arteries I'm comfortable with, but veins? Not so much. Thank you in advance!

The codes that I have found thus far are 35476, 75978, 37187, 36005, 75820, and 36010. I'm sure there is a lot I'm missing.

Indications: A 59-year-old white make whi had bilateral DVT and saddle embolism 2 months ago. We placed an IVC filter in him because of hemodynamic compromise. He was then sent home on Coumadin. He has had a persistent swelling of his lower extremities, but came in with anasarca, scrotal edema and a profound right lower extremity swelling more than left several days ago. His INR was subtherapeutic. We started him on heparin. Noninvasive studies confirmed occlusions with thrombus in the iliac veins and inferior vena cava. We brought him down electively for intervention on his right lower extremity initally. 

1.  With the help of ultrasound, we accessed the right popliteal vein. We used the micropuncture kit. We then placed a long 7-French Destination sheath at the level of the proximal right superficial femoral vein. It should be noted that we confirmed that we were in the popliteal vein by performing angiography through the micropuncture kit.
2.  We then performed a right superficial femoral vein angiogram through the sheath and this showed occlusive thrombus at the level of the right common femoral vein. There was no antegrade flow.
3.  We started Angiomax.
4.  We then took a Glidewire and a glide catheter and crossed the occluded femoral vein, iliac vein, and inferior vena cava uneventfully. The thrombus throughout that region was quite soft.
5.  I did place my glide catheter beyond the previously placed inferior vena cava and performed an angiogram in the proximal inferior vena cava confirming that we were in fact intraluminal and there was excellent blood flow beyond the vena cava filter.
6.  I then took the glide catheter out and used a 0.035 wire that was placed through the vena cava filter uneventfully.
7.  We then performed pulsed AngioJet thrombectomy with TPA. We performed AngioJet thrombectomy at the level of the right common femoral vein, the right iliac veins, and the inferior vena cava into the inferior vena cava filter. We performed multiple runs.
8.  We then performed aggressive balloon angioplasty with a 10 X 40-mm balloon at the level of the right common femoral vein, the right iliac veins, and the inferior vena cava.
9.  Results were still suboptimal and so we went ahead and performed another AngioJet thrombectomy run throught the occluded segment.
10.  We performed angiography at the multiple levels including the common femoral vein, the iliac veins, and the inferior vena cava in order to localize the residual thrombus. There was, in fact, fairly extensive thrombus at the distal end of the inferior vena cava filter.
11.  I then took a 7-French Amplatz guide and performed suction atherectomy through the guide and we debulked the thrombus considerably. 
12.  I then performed further balloon inflations throughout the level of the IVC, iliac veins, and femoral veins.
13.  Final angiography showed very reasonable flow throughout the right femoral vein, iliac veins, and the IVC. A very satisfactory result. Although there was residual thrombus, I am hopeful that this will dissolve with time and anticoagulation. 
14.  The lond 7-French Destination sheath was then exchanged for a short 7-French sheath.

Thanks again!
Leah


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## dpeoples (Apr 4, 2011)

leahlhaynie said:


> This is the first time one of our doctors has done a venous intervention, and I would appreciate any help that could be provided. Arteries I'm comfortable with, but veins? Not so much. Thank you in advance!
> 
> The codes that I have found thus far are 35476, 75978, 37187, 36005, 75820, and 36010. I'm sure there is a lot I'm missing.
> 
> ...



I would code:
35476/75978 for the angioplasty of the vena cava
35476-59/75978-59(or 76 depending on payor preference) for RT femoral/iliac veins.
37187 for the venous thrombectomy (once)
36010 catheter placement to vena cava
75820 venography of RT lower extremity
75825 venography of IVC.

HTH


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## leahlhaynie (Apr 5, 2011)

dpeoples said:


> I would code:
> 35476/75978 for the angioplasty of the vena cava
> 35476-59/75978-59(or 76 depending on payor preference) for RT femoral/iliac veins.
> 37187 for the venous thrombectomy (once)
> ...



Perfect! After reading the descriptions it's starting to make a lot more sense. Thank you so much!

Leah


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