# Embolization with coils balloon and stent



## SPECIALTYCODING (Mar 15, 2019)

Hi  I'm looking for some guidance for coding the following procedure.  Any help would be greatly appreciated 


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INDICATION: 57 y.o. female with multiple cerebral aneurysms
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COMPARISON: CTA performed on 
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ANESTHESIA: General Anesthesia.
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CONSENT: 
The procedure, risks, benefits and alternatives to cerebral angiography were discussed with the patient. Informed consent was obtained after all questions were answered. The patient was brought to the Neuroendovascular suite and placed supine on the angiography table. The patient was prepped and draped in the usual sterile fashion.
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DESCRIPTION OF THE PROCEDURE AND FINDINGS: 
ACCESS: 
The skin of the right wrist was anesthetized with EMLA cream and 2% lidocaine subcutaneously.  Utilizing US guidance and a micropuncture kit, a 6 Fr. Terumo slim glidesheath was placed into the right radial artery.  2D hand injected angiography was performed which demonstrates retgrade opacification of the radial artery, ulnar artery and superficial palmar arch.  Heparin 5000 units, 200 mcgs Nitroglycerin and 5 mg verapamil was adminsitered intra-arterially.
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Intravenous heparin was administered with intermittent boluses to maintain an ACT 2 - 2.5 times the patient’s baseline.
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A 6 French 071 Benchmark guide catheter over a Simmons-2 catheter and an angled 0.038" Terumo Glidewire was advanced into the right brachial artery.
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RIGHT VERTEBRAL ARTERY:
The guide catheter was advanced into the right vertebral artery.  2D hand injected angiography was performed centered over the neck and head.  The cervical vertebral artery is of normal course and caliber.  Intracranially, there is antegrade opacification of the right vertebral artery, right posterior inferior cerebellar artery, basilar artery, bilateral anterior-inferior cerebellar arteries, bilateral superior cerebellar arteries, bilateral posterior cerebral arteries and their branches.  The left distal vertebral artery backfills briefly with opacification of the left posterior inferior cerebellar artery. The vessels are of normal course, caliber and taper regularly.  There is no aneurysm, focal area of stenosis or early draining vein.  The capillary and venous phases are unremarkable.  The dural and deep venous sinuses opacify normally.
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LEFT COMMON CAROTID ARTERY:
The guide catheter was advanced into the left common carotid artery.  2D hand injected angiography was performed centered at the bifurcation which is at the C2/3 level. The carotid bifurcation is widely patent without atherosclerotic disease or hemodynamic significant stenosis.  The cervical internal and external carotid arteries are of normal course and caliber.
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LEFT EXTERNAL CAROTID ARTERY:
The guide catheter was advanced into the left external carotid artery.  2D hand injected angiography was performed centered over the patient’s head.  Angiography reveals antegrade opacification of the external carotid artery and its branches.  The vessels are of normal course, caliber and taper regularly.  No aneurysm, focal area of stenosis or early draining vein is seen to suggest a fistula.
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LEFT INTERNAL CAROTID ARTERY:
The guide catheter was advanced into the left internal carotid artery.  2D hand injected cerebral angiography was performed in the AP, lateral and oblique projections.  Angiography reveals antegrade opacification of the internal carotid artery, middle cerebral artery, anterior cerebral artery and their branches. The posterior communicating artery is small, fills the posterior cerebral artery and rapidly clears from competitive flow. The vessels are of normal course, caliber and taper regularly.  There is no focal area of stenosis or early draining vein.  The capillary and venous phases are unremarkable.  The dural and deep venous sinuses opacify normally. There is a 2.2 mm x 2.4 mm left ophthalmic artery aneurysm.
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RIGHT COMMON CAROTID ARTERY:
The guide catheter was advanced into the the right common carotid artery.  2D hand injected angiography was performed centered at the bifurcation which is at the C2/3 level. The carotid bifurcation is widely patent without atherosclerotic disease or hemodynamic significant stenosis.  The cervical internal and external carotid arteries are of normal course and caliber.
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RIGHT INTERNAL CAROTID ARTERY:
The guide catheter was advanced into the right internal carotid artery.  2D hand injected cerebral angiography was performed in the AP, lateral and oblique projections.  Angiography reveals antegrade opacification of the internal carotid artery, middle cerebral artery, anterior cerebral artery and their branches. The posterior communicating artery is robust, fills the posterior cerebral artery and rapidly clears from competitive flow. The vessels are of normal course, caliber and taper regularly. There is no focal area of stenosis or early draining vein. The capillary and venous phases are unremarkable. The dural and deep venous sinuses opacify normally. There is a 2.9 mm x 6.1 mm right posterior communicating artery aneurysm with a 3 mm neck. There is a 3.6 mm x 3.5 mm right paraophthalmic aneurysm with a 2.5 mm neck. There is an occlusion of a distal parietal middle cerebral artery branch with delayed opacification of the downstream territory. 7.35 mg of Integrilin were administered to the right internal carotid artery.
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EMBOLIZATION: 
The right internal carotid artery was selected and under roadmap guidance and 10 mg of verapamil was administered. The guide catheter and glidewire were advanced into the cervical segment of the internal carotid artery. The Simmons-2 catheter and glidewire were removed. Follow-up control angiography was performed which is unchanged from the initial angiogram and demonstrated no vasospasm around the guide catheter. There is slight improvement in opacification of the occluded distal parietal middle cerebral artery branch. 
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Utilizing a road map a 4 mm x 10 mm Scepter C balloon was advanced over a 0.014" Synchro-2 guidewire across the right posterior communicating artery aneurysm os. A 45 degree SL-10 microcatheter was advanced over a 0.014" Aristotle guidewire into the right posterior communicating artery aneurysm. An aneurysmogram was performed which demonstrates opacification of 2.9 mm x 6.1 mm aneurysm with a 3 mm neck.
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Balloon assisted coil embolization of the aneurysm was performed by advancing a TARGET 360 SOFT 5X10 coil into the aneurysm. This was followed by a TARGET 360 ULT 4X10 coil, which prolapsed out of the aneurysm sac. The coil was removed and the balloon deflated, resulting in a coil loop prolapsing into the right internal and right middle cerebral arteries. The 45 degree SL-10 was removed. A 90 degree SL-10 microcatheter was advanced over a 0.014" Aristotle guidewire into the right posterior communicating artery aneurysm under roadmap control. Balloon assisted coil embolization of the aneurysm was performed by advancing the TARGET 360 ULT 3X8 coil. Control angiography demonstrates a coil loop within the right middle cerebral artery and the right internal carotid artery, otherwise the remaining coils are well seated in the aneurysm sac and the parent vessel to be widely patent.
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Coil embolization of the aneurysm was performed by advancing the following coils into the aneurysm sac:
TARGET 360 ULT 3X8
TARGET 360 ULT 3X6
TARGET 360 ULT 2X4
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Follow up control angiography was performed demonstrating a coil loop within the right middle cerebral artery and the right internal carotid artery, otherwise the remaining coils are well seated in the aneurysm sac and the parent vessel to be widely patent.
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Utilizing a road map the 4 mm x 10 mm Scepter C balloon was advanced over the 0.014" Synchro-2 guidewire across the right paraophthalmic aneurysm os. The 90 degree SL-10 microcatheter was advanced over the 0.014" Aristotle guidewire into the right paraophthalmic aneurysm. An aneurysmogram was performed which demonstrates opacification of 3.6 mm x 3 mm aneurysm with a 2.8 mm neck.
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Balloon assisted coil embolization of the aneurysm was performed by advancing a MICRUSFRAME 10 3.5X6.6 coil into the aneurysm sac. Control angiography demonstrates the coil mass seated in the aneurysm sac and the parent vessel to be widely patent.
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Coil embolization of the aneurysm was performed by advancing the following coils into the aneurysm sac:
GALAXY G3 MINI 2.5X4.5
GALAXY G3 MINI 2X3
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The Scepter C balloon and SL-10 catheter were removed.
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Under high magnification fluoroscopic roadmap control, a 4.5 mm x 21 mm Neuroform Atlas stent was positioned from the right carotid terminus to the cavernous segment segment of the right internal carotid artery utilizing a XT-17 over the 0.014" Aristotle guidewire and deployed.
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Control angiography demonstrates a coil loop arising from the right posterior communicating artery aneurysm coil mass into the right middle cerebral artery, with the remaining coils to be well seated in the aneurysm sac and the parent vessel to be widely patent with no opacification of the aneurysm sac, but persistent filling of the aneurysm neck (Raymond 2). Additionally, there is a coil mass seated in the right paraophthalmic aneurysm with no opacification of the aneurysm sac (Raymond 1). There is no evidence of in stent stenosis or thrombosis, and the stent is well apposed to the parent vessel wall.
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The XT-17 microcatheter and guidewire were removed. Final follow-up control angiograms were performed in the AP, lateral and working projections which demonstrated the coil mass to be well seated within the aneurysm sac and the parent vessel to be widely patent.  There is persistent occlusion of the distal parietal middle cerebral artery branch with delayed opacification of the downstream territory.
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After review of the angiographic data the guide catheter was removed. The right radial artery sheath was removed. Hemostasis was achieved utilizing a TR-Band. The patient tolerated the procedure well. The patient was subsequently transferred to the Neuroendovascular Surgery recovery area at their baseline neurological status. 
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IMPRESSION: 
1. Balloon assisted coil embolization of a non-ruptured, right posterior communicating artery aneurysm measuring 2.9 mm x 6.1 mm with a 3 neck. There is no opacification of the aneurysm sac, but persistent filling of the aneurysm neck (Raymond 2). There is a coil loop in the right internal carotid and right middle cerebral arteries.
2. Successful balloon assisted coil embolization of a non-ruptured, right paraophthalmic aneurysm measuring 3.6 mm x 3.5 mm with a 2.5 mm neck. There is no opacification of the aneurysm sac (Raymond 1). 
3. Atlas stent deployment from the right internal carotid terminus into the cavernous segment of the right internal carotid artery, successfully tacking down the prolapsed coil loop.
4. Occlusion of the distal parietal middle cerebral artery branch with delayed opacification of the downstream territory treated with Integrilin infusion.
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MY CPT CODES

61624 
36226 RT
36224 50
36228 X 2
75894 26
75898 X 2
NOT SURE ABOUT THE ATLAS STENT  Included?

Thank you!


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