# BRTO bALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION



## whittyamy (Dec 29, 2010)

Please I need help!!! My IR docs are starting to do this procedure and I cannot find a code for this and I am not sure if one even exists. They are using alcohol like a scleratherapy but then they are saying that they are embolizing. Here is how it reads....



A micropuncture needle was used to gain access to the right common femoral vein. Through this, an 018 wire was then placed and
over-the-wire, a micropuncture catheter was placed into the normal vein. Through this an 035 Rosen wire was placed into the
inferior vena cava. Over the Rosen wire, a 7 French 45 cm sheath was then placed. Through the sheath, a 5 French Simmons 2
catheter was placed into the left renal vein.

Contrast was injected with digital subtracted imaging and the venogram demonstrated extensive inflow and a large superior there is
seen consistent with the patient's gastric varices and shunt.

Therefore, multiple catheters and wires were used to attempt to selectively catheterize the shunt from this right groin access but
due to severe angulation of the left renal vein, this cannot be performed. Therefore, this access was abandoned and the sheath was
removed. Approximately 5 minutes of manual compression were held at the sheath for hemostasis.

Attention was turned to the patient's right neck. The soft tissues overlying the internal jugular vein were then prepped and
draped in sterile fashion. 1% lidocaine was introduced in subcutaneous tissues for local anesthesia.

Utilizing ultrasound guidance, a micropuncture needle was used to gain access to the right internal jugular vein. An a 18 wire was
then placed through the superior vena cava into the inferior vena cava. A small dermatotomy was made in the skin with 11 blade
scalpel and a micro- catheter was then placed. Through the microcatheter, a 035 wire was then placed into the inferior vena cava.
Over-the-wire, a 7 French sheath a was placed into the inferior vena cava at the level of the left renal vein. Through this, a 5
French Cobra catheter and a 035 Glidewire were used to selectively catheterize the left renal vein.

Contrast was injected which is subtracted imaging of the left renal vein which demonstrated significant inflow and again a large
varices.

Due to the severe inflammation, the Cobra catheter was then exchanged over a wire for a Simmons 2 catheter. Through the Simmons 2
catheter a Prowler catheter 018 Sparta core wire were used to selectively catheterize more distally within the shunt.

Over the 018 Sparta core wire and the microcatheter the Simmons 2 catheter was then advanced distally within the shunt. The
microcatheter and wire were removed and venogram of the shunt demonstrated extensive variceal drainage.

Through the Simmons 2 catheter, a 035 Rosen wire was placed into the shunt distally, the Simmons 2 catheter was removed and over
the wire, 15 mm occlusion balloon was placed into the varices and inflated. 

Contrast was injected through the end hole confirming complete occlusion of the varices.

Next, through the endhole, approximately 8 cc of 1% Sotradecol in a 2:1 ratio was used to embolize  the varices until stagnation
of flow was visualized.

The sheath and catheter were then secured to the skin with a through a Prolene suture and a sterile dressing was applied.

Impression: 
Large gastric varices with shunts as described above.
Embolization of the shunt with occlusion balloon left in place to allow sclerosis to continue overnight.

We will bring the patient back within 12 hours to evaluate for adequacy of embolization.


If anyone knows anything about these please respond, your help is much appreciated!!


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## Anug123 (Jan 3, 2011)

I think this can be coded with 36470, since the procedure is performed to occlude the varicose vein using sclerotherapy & also the CPT description states as follows...

The physician injects a sclerosing solution into veins of the leg. The physician inserts a tiny needle through the skin and directly into any single vein (in 36470) or multiple veins of the same leg (in 36471). A solution (hypertonic saline and other solutions) is injected into these veins. The patient stands while the injection is given. The leg is elevated thereafter, and wrapped in an elastic dressing. *The solution causes the walls of the veins to become inflamed, collapse, and stick together so the veins close.*

Regards
Prabhavathi


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## whittyamy (Jan 4, 2011)

*Brto*

Thank you for replying to my post. And I see where you are coming from, but the code specifically states leg and this is a renal vein so I don't think it would be appropriate.


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## Anug123 (Jan 4, 2011)

Oops!!! That's right!  then you need to opt for Unlisted procedure codes.

I doubt whether this procedure is done to repair the TIPS Shunt...

Thanks
Prabhavathi


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