# Epistaxis case



## Liza559 (Oct 15, 2012)

Hi,
Would someone be able to verify the codes for this case. 
Neuro, sometimes, is a challenge and frustrating.
Thank you in advance 

75662,75671,76937,75898,61626,75894,75774,75774.59(7),36216,36217,36218,36218.59(6)


REPORT:   EPISTAXIS EMBOLIZATION

INDICATION:  63-year-old female with a history of seasonal allergies presented with recurrent bilateral, right greater than left, epistaxis requiring initial cauterization and nasal packing, but returned and was admitted to Northwest Community Hospital requiring balloon packing in the right nasal cavity.  Further refractory epistaxis was noted and required repacking with both anterior and posterior nasal balloons on the right by the Otolaryngology Service.  Due to the patient's recurrent and refractory epistaxis as well as anemia, our service was consulted for bilateral sphenopalatine and right facial artery embolization for definitive treatment.

COMPARISON:  None.

ATTENDING SURGEON:  Sameer A. Ansari, M.D., PhD. was present and scrubbed for the entire duration of the procedure.

PROCEDURES:
1.  Informed consent.
2.  Percutaneous right common femoral artery access under fluoroscopic and ultrasound guidance (76937).
3.  Retrograde placement of 5 French shuttle sheath.
4.  Right internal carotid artery catheterization and biplane/magnified intracranial angiograms (36217). 
5.  Right external carotid artery catheterization and biplane cervical angiograms
6.  Superselective microcatheter placement into right internal maxillary artery and four biplane angiograms.36218-75774
7.  Superselective microcatheter placement into right sphenopalatine artery and biplane angiograms.36218.59-75774.59
8.  Particle embolization of right sphenopalatine artery and biplane check angiograms.61626-75894
9.  Gelfoam embolization of right sphenopalatine artery and right internal maxillary/right external carotid artery biplane check angiograms.
10.  Superselective microcatheter placement into right facial artery and biplane angiograms. 36218.59-75774.59
11.  Superselective microcatheter placement into the right facial artery-alar branch and two biplane angiograms.36218.59-75774.59
12.  Particle embolization of right facial artery-alar branch and biplane check angiograms.
13.  Gelfoam embolization of right facial artery-alar branch and biplane check angiograms.
14.  Final right external carotid artery biplane angiograms post-embolization.
15.  Final right common carotid artery biplane intracranial angiograms post-embolization.75774.59
16.  Left internal carotid catheterization and biplane/magnified oblique intracranial angiograms.36216- 75671
17.  Left external carotid artery catheterization and biplane cervical angiograms. 75662
18.  Superselective microcatheter placement into the left internal maxillary artery and biplane angiograms.36218.59-75774.59
19.  Superselective microcatheter placement into the left sphenopalatine artery and biplane check angiograms.36218.59-75774.59
20.  Gelfoam embolization of left sphenopalatine artery and left internal maxillary artery biplane check angiograms.
21.  Final left external carotid biplane angiograms post-embolization.75898
22.  Final left common carotid artery biplane intracranial angiograms post-embolization.75774.59
23.  Removal of catheters and sheath with hemostasis via manual compression.

TECHNIQUE/FINDINGS:  
The patient provided informed consent following explanation of the procedure, indications, benefits, risks/complications and alternatives.  The possible risks/complications were discussed in detail including general anesthesia, pain, infection, bleeding, groin hematoma/leg ischemia, vessel dissection, stroke, unsuccessful or inadvertent embolization leading to skin/soft tissue necrosis, cranial neuropathies, vision loss, stroke, pulmonary emboli, contrast rash/nephropathy, radiation, and even death.

The patient was brought to the angiography suite and placed supine on the table.  Following induction of general endotracheal anesthesia, both groins were prepped and draped in sterile fashion.  Vascular access was obtained in the right common femoral artery using a 5 French micropuncture set under fluoroscopic and ultrasound guidance.  Retrograde placement of a 5 French shuttle sheath was performed over a Bentson .035 inch wire.  An inner 5 French 125 cm vertebral catheter was advanced over the Bentson .035 wire across the aortic arch and used to catheterize the bilateral common carotid arteries with selective catheterization of the bilateral internal/external carotid arteries under roadmap guidance using a Terumo .035 glidewire.  Biplane digital subtraction angiography was performed at the cervical and intracranial levels. 

Please note patient received 3,000 units of intravenous heparin at the onset of the procedure with activated clotting times ranging from the baseline of 109 to 179 seconds.  

Right internal carotid artery injections:  Standard AP/lateral DSA images demonstrate normal antegrade opacification through the distal cervical, petrous, cavernous, and supraclinoid segments of the right internal carotid artery, right anterior and middle cerebral arteries.  A prominent right posterior communicating artery opacifies the right posterior cerebral artery distribution.  Prominent anterior ethmoid branches are noted arising from the distal right ophthalmic artery and extend inferomedially to supply the nasal cavity.

Right external carotid artery injections:  AP/lateral DSA images demonstrate normal antegrade opacification through the right lingual, facial, occipital, superficial temporal, middle meningeal, and internal maxillary arteries.  Although the right sphenopalatine arteries are not well opacified due to contrast washout, a prominent right facial artery is present with notable angular/alar branch extending superiorly.  

The 5 French shuttle sheath was coaxially advanced over the 125 cm vertebral catheter in the right external carotid artery for adequate guide support.  Although we attempted to superselectively catheterize the distal right internal maxillary and right sphenopalatine arteries using a Excelsior 1018 microcatheter and Synchro-2 standard .014 inch microwire, the significant vessel tortuosity required triaxial support, and the microcatheter was then coaxially advanced through a DAC 044 115 cm catheter via the 5 French shuttle sheath in the right external carotid artery.  With difficulty, the Excelsior 1018 microcatheter was advanced into the distal right internal maxillary artery as noted on four distal right internal maxillary artery microcatheter check angiograms.  Further tortuosity was evident in the superselective catheterization of the right sphenopalatine artery with approximately three 180 degree turns which we were able to traverse using the Synchro-2 standard .014 inch microwire and our triaxial support by advancing the DAC 044 catheter into the right internal maxillary artery.  Prominent nasal septal and turbinate branches were noted arising from the distal right sphenopalatine arteries, confirmed on biplane microcatheter check angiograms prior to particle embolization.  We were able to obtain distal microcatheter purchase away from the descending palatine artery though contrast reflux did opacify this branch.  Particle embolization was initiated slowly to prevent any particle reflux under constant negative roadmap fluoroscopy using 300-500 micrometer Embospheres. Embospheres were infused for a total of 5 mL (.25 vials) until contrast stasis indicated saturation of the capillary nasal vascular bed and no residual opacification of the  right sphenopalatine branches on biplane microcatheter check angiogram.  Next, Gelfoam embolization with two pledgets was infused through the microcatheter into the right sphenopalatine and it was withdrawn with two right external carotid artery biplane check angiograms demonstrating no significant residual vascular supply to the right posterior nasal cavity and slow antegrade flow in the distal right internal maxillary artery terminating in the infraorbital branch status-post Gelfoam embolization.  However, a prominent right facial artery-alar branch remained supplying the right anterior nasal cavity.

The triaxial DAC 044 and Excelsior 1018 microcatheter were again advanced over the Synchro-2 standard .014 inch microwire into the proximal right facial artery, confirmed on right facial artery biplane check angiograms past the mental branch and opacifying the inferior labial, superior labial and the alar branches.  Vasospasm was noted at the tip of the DAC 044 microcatheter and it was slightly withdrawn.  The Excelsior 1018 microcatheter was now advanced over an Xpedion-10 microwire with a tight J-loop and was able to superselectively catheterize the alar branch of the right facial artery, past the superior labial branch, seen on two biplane check angiograms with multiple anterior projecting pedicles supplying the nasal cavity.  Particle embolization was initiated with 300-500 micrometer Embospheres as described above for a total of 3 mL until contrast stasis was noted indicating saturation of the vascular bed and no significant antegrade flow was seen on biplane microcatheter check angiograms.  Gelfoam embolization was initiated with infusion of two pledgets into the right facial artery-alar branch, and right facial artery biplane check angiograms through the DAC 044 catheter after the Excelsior 1018 was removed demonstrated prominent opacification of mental and inferior labial branch and slow antegrade flow into the distal right facial artery opacifying the superior labial branch, but no residual antegrade supply into the alar branch or nasal vascularity consistent with particle and Gelfoam occlusion.  

Final right external carotid artery biplane check angiograms demonstrated normal antegrade opacification of the right occipital, superficial temporal, and middle meningeal arteries.  Post-embolization changes are noted with truncation of the distal right facial artery and internal maxillary artery with no significant residual nasal vascular supply to the anterior or posterior nasal compartments.  Vasospasm is noted in the right external carotid artery distal to the right facial artery origin, probably due to the 5 French shuttle sheath advancement required for right sphenopalatine artery superselective catheterization; hence, we infused 5 mg of verapamil intra-arterially through the 5 French shuttle sheath prior to retraction in the right common carotid artery.  Final right common carotid artery biplane intracranial angiograms redemonstrate normal antegrade opacification through the distal cervical, petrous, cavernous and supraclinoid segments of the right internal carotid artery, right anterior and middle cerebral arteries.  Prominent right posterior communicating artery is again seen opacifying the right posterior cerebral artery distribution.  There has been no interval recruitment of the anterior ethmoid branches of the right ophthalmic artery to the right nasal cavity though residual supply to the nasal septum remains.  There is no evidence of filling defect, delayed contrast opacification, or contrast washout in the distal intracranial vasculature to suggest interval  thromboembolic complication.  The capillary and venous phases are unremarkable.  

Left internal carotid artery injections:  Standard AP/lateral DSA and magnified oblique DSA images demonstrate normal antegrade opacification through the distal cervical, petrous, cavernous, and supraclinoid segments of the left internal carotid artery, left anterior and middle cerebral arteries.  A prominent left posterior communicating artery opacifies the left posterior cerebral artery distribution.  Anterior ethmoid branches are identified extending anteroinferiorly from the left ophthalmic artery supplying the left nasal cavity.

Left external carotid artery injections:  Standard AP/lateral DSA images demonstrate normal antegrade opacification through the left lingual, facial, occipital, superficial temporal, middle meningeal, and internal maxillary arteries.  Prominent left sphenopalatine arteries are identified arising from the distal left internal maxillary artery supplying the posterior left nasal cavity, but there does not appear to be a prominent left facial artery or alar branches extending to the anterior left nasal cavity. 

The 5 French shuttle sheath was again coaxially advanced into the proximal left external carotid artery over the 5 French 125 cm vertebral catheter and it was then removed.  Triaxial catheter support using the DAC 044 115 cm catheter and Excelsior 1018 microcatheter over a Transcend .014 inch floppy tip microwire was performed into the distal right internal maxillary artery, again confirming a tortuous course of the right sphenopalatine arteries, distal to the infraorbital and descending palatine branches.  Prominent left sphenopalatine arteries were observed opacifying the posterior left nasal cavity.  

Utilizing DAC 044 catheter support in the distal left internal maxillary artery, the Excelsior 1018 microcatheter was advanced into the left sphenopalatine artery at the bifurcation of the turbinate and septal branches, confirmed on biplane microcatheter angiograms.  Particle embolization was initiated with 300-500 micrometers Embospheres for a total of 5 mL (.25 vials) until contrast stasis was noted and no residual sphenopalatine arteries were identified on biplane microcatheter check angiogram.  Finally, two Gelfoam pledgets were infused through the Excelsior 1018 microcatheter into the left sphenopalatine artery and the microcatheter was removed.  Distal left internal maxillary artery biplane check angiograms through the DAC 044 microcatheter demonstrated slow antegrade flow opacifying the infraorbital branch, but no significant antegrade flow into the descending palatine or left sphenopalatine arteries.  Final left external artery biplane angiograms post-embolization redemonstrate devascularization of the left posterior nasal cavity and slow antegrade flow into the distal left internal maxillary artery as described.  There does not appear to be any significant recruitment from the left external carotid artery branches to the nasal cavity nor is there a prominent alar branch from the left facial artery supplying the left anterior nasal cavity.  The 5 French sheath was retracted into the left common carotid artery and final left common carotid artery biplane intracranial angiograms redemonstrated normal antegrade opacification through the distal cervical, petrous, cavernous, and supraclinoid segments of the left internal carotid artery, left anterior and middle cerebral arteries.  Prominent left posterior communicating artery opacifies the left posterior cerebral artery distribution.  There is no evidence of interval thromboembolic complication in the distal intracranial vasculature.  The capillary and venous phases are unremarkable.  Anterior ethmoid branches from the distal left ophthalmic artery are unchanged and extend anteroinferiorly to supply the nasal cavity, but are not amenable to embolization.

The 5 French sheath was retracted into the descending aorta.  Following reversal of heparin anticoagulation with 20 mg of protamine and normalization of activated clotting times, the 5 French shuttle sheath was removed, and adequate hemostasis was achieved with manual compression for 15 minutes.  The patient tolerated the procedure well with no immediate complications.

MEDICATIONS: 
1.  General endotracheal anesthesia.
2.  Ancef 1 gram IV.
3.  Heparin 3,000 units IV.
4.  Verapamil 5 mg IA.
5.  Protamine 20 mg IV.
6.  Decadron 10 mg IV.

CONTRAST:  150 mL Visipaque-320.
RADIATION:  971 mGy.

IMPRESSION:
1.  Successful particle and Gelfoam embolization of bilateral sphenopalatine and right facial-alar arteries.
2.  Bilateral ophthalmic-anterior ethmoid artery supply to the nasal vasculature.


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## diann@jasonrbaileymd.com (Sep 7, 2021)

I was wondering if you ever figured this out. I know a lot has changed since this post but I would like the advice as well on this particular case.


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## Jim Pawloski (Sep 8, 2021)

If you want present day codes, I would use 36224-50, 36227-50, 61624, 75894, 75898 x 2


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## diann@jasonrbaileymd.com (Sep 8, 2021)

Jim Pawloski said:


> If you want present day codes, I would use 36224-50, 36227-50, 61624, 75894, 75898 x 2


Thank you I appreciate your help


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