# Thrombectomy help



## MELJNBBRB (Feb 19, 2015)

Need some help list
Busy case here
75630
37184
37185 36247 36248
36870
37238
36147

I am gathering he did thrombectomy of the arteries and veins. 

TIA






PREOPERATIVE DIAGNOSIS:
Clotted, failing right groin loop PTFE.


POSTOPERATIVE DIAGNOSIS:
Clotted, failing right groin loop PTFE.


PROCEDURE PERFORMED:
Declot right groin loop PTFE stent with 157 mm x 150 mm
covered stent and angioplasty with 6 x 100 mm balloon,
thrombectomy right popliteal artery, thrombectomy right
posterior tibial artery and thrombectomy right anterior tibial
artery, tPA thrombolysis right anterior tibial artery, and
left femoral central line placement.


INDICATIONS:
The patient is a very well known 34-year-old dialysis patient
who was on his probably last access and it is failing.  I was
asked to evaluate it.  They were concerned it was going to
clot and in fact, before he got here today, it did clot. They
have been having poor flow issues.  I discussed with Johnny
and his family the risks, benefits, alternatives of the
procedure and informed consent was obtained.


PROCEDURES:
He was placed in the supine position, prepped and draped in a
standard sterile fashion as nobody could get venous access on
him.  I placed a left femoral central line and gave him Versed
and Dilaudid for sedation.  I then infiltrated lidocaine
overlying the lateral loop of the graft and attempted to
access it as there was no flow in this; it was basically a
blind access.  I was able to draw back some blood.  Eventually
I did get a little bit of flow as I advanced this catheter and
then I took an angiogram and unfortunately, I had pushed some
clot into the common femoral artery from the graft itself.  At
this point, I went ahead and accessed the left common femoral
artery percutaneously and placed a sheath and then I used an
Omniflush catheter to perform aortogram with iliofemoral
runoff.  He had very interesting aortic anatomy with 2
bifurcations.  I got up and over using the Omniflush and the
Glidewire, had a lot of trouble getting a Destination sheath
up and over, had to use some multipurpose catheter as well as
a wire and the sheath to finally get this over and placed the
Destination sheath in the common femoral artery.  I then ran
the right leg; this clot had pushed down to the popliteal
artery just at the tibio-peroneal trunk, so we used the
Angiojet device and performed multiple passes with the
Angiojet in the popliteal artery and that was successful at
opening this up; however, the clot pushed distally into the
anterior tibial and posterior tibial artery.  I then advanced
an 0.014 guidewire into the posterior tibial first and then
the anterior tibial and was able to clear the posterior tibial
completely of clot.  The anterior tibial I was able to clear
to about the distal calf and this reconstituted via peroneal
collaterals.  The peroneal did not ever demonstrate flow.  I
then placed a straight catheter into the anterior tibial
artery, injected 2 mg of tPA in hopes that this very distal
clot would dissolve.  The patient was awake and 2 hours into
this, he was still asymptomatic in the leg.  I then turned my
attention towards the graft itself, I then backed out my
equipment, advanced the guidewire into the graft, cannulated
it all the way into the vena cava and performed Angiojet
thrombolysis on the PTFE graft itself and was able to regain
flow.  He had a very diseased graft at the apex of the graft
for a distance of about 180 cm.  I placed a covered stent
measuring 7 mm across the apex of this graft to try and open
up the flow and there was still very significant disease
proximal to this.  I selected a 6 mm balloon with a prolonged
insufflation here and this improved, but did not completely
resolve the stenosis.  I did not want to place the stent
across the entire length of the graft due to concern for
access at a later date.  He did have excellent flow and at the
end of this, the sheath that I had placed initially into the
graft itself was removed and I placed a silk stitch there.  I
then showed a sheathogram in the left groin, I felt the artery
was too small caliber to close.  So we pulled the catheter and
held pressure.  Complication was embolus to the femoral and
popliteal arteries as well as a distal infrapopliteal
arteries; this was resolved with thrombolysis.  He seemed to
tolerate the procedure well.  He will be admitted to the
hospital rather than sent home today and I have notified the
nephrology service.


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## ccollison (Feb 23, 2015)

I think it is: 37230 stent, 37186 thrombectomy secondary to stent, 37184-59 thrombectomy, 37185-59 thrombectomy, 37211 TPA, 36215 catheter, 75630-26 angiography. All arterial, no veins. 
C Collison CPPM, CCC


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