# AngioVac Thrombectomy



## dlrodrig1 (Feb 5, 2015)

All coding advice for this procedure would be greatly appreciated!

Pt. was brought to the hypbrid OR and identified.  She underwent induction of general anesthesia followed by placement of an endotracheal tube and foley catheter.  A radial arterial line was placed.  Her neck, chest, abdomen and both groins were now prepped and draped.  A 5 french sheath was now positioned within the left common femoral artery and a 6 french sheath in the left common femoral vein.  (these were placed for rapid institution of peripheral ECMO should it become necessary).  The patient was systemically heparinized at this point.  Using fluroscopic guidance, the right common femoral vein was percutaneous cannulated with a 20 French reperfusion cannula, positioned within the right common iliac artery.  We now passed a 5 french pigtail catheter into the left common femoral vein over a soft wire and advanced this catheter to the level of the mid-IVC.  Venography was now performed, showing the thrombus related filling defect at the junction of the right atrium.  We now turned our attention to the right neck.  The right internal jugular vein was accessed and a wire was passed to the level of the distal SVC.  The track was dilated and finally a Gore 26 french Dry sheath was passed over a dilator into the right IJ vein and advanced to the level of the SVC.  The sheath was flushed.  The angiovac 24 french balloon tipped drainage cannula was now passed through this sheath under fluroscopic guidance and positioned at the SVC/RA junction.  The balloon was expanded and extra-corporeal venous drainage was initiated.  4 liter/min of flow was obtained.  We advanced the balloon drainage cannula through the right atrium onto the thrombus in the IVC.  Debulking of the clot was successful after several passes.  White (chronic) clot was extracted and observed in the circuit filter.  After 45 minutes of therapy, TEE was used to assess results.  The presenting mobile thrombus at the RA/IVC junction had been removed with unobstructed flow into the right atrium identified.  No further thrombus was seen in the terminal IVC.  Venography was performed, again from the right groin pigtail catheter.  Some minor filling defect remains in the mid IVC, indicative of chronic, adherent thrombus.  This was not retrieved.  Hemodynamics remained stable throughout.  

Under fluroscopic guidance, the drainage and reperfusion cannulas were each removed from the IJ and right CFV, respectively.  Protamine was administered (1/2 dose) and the 26 french sheath was removed from the right IJ.  Direct pressure was applied to both the right IJ and right CFV to endure hemostasis.  The sheaths were removed from the left groin as well and all wounds were covered with sterile dressings.  The patient tolerated the procedure well.  She is extubated within the OR with stable BP and some noticeable bronchospasm which will be addressed with bronchodilator therapy.  Plan is to reassess both venous access sites at 6 hours post-op and begin heparin infusion if able.


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## Jim Pawloski (Feb 24, 2015)

dlrodrig1 said:


> All coding advice for this procedure would be greatly appreciated!
> 
> Pt. was brought to the hypbrid OR and identified.  She underwent induction of general anesthesia followed by placement of an endotracheal tube and foley catheter.  A radial arterial line was placed.  Her neck, chest, abdomen and both groins were now prepped and draped.  A 5 french sheath was now positioned within the left common femoral artery and a 6 french sheath in the left common femoral vein.  (these were placed for rapid institution of peripheral ECMO should it become necessary).  The patient was systemically heparinized at this point.  Using fluroscopic guidance, the right common femoral vein was percutaneous cannulated with a 20 French reperfusion cannula, positioned within the right common iliac artery.  We now passed a 5 french pigtail catheter into the left common femoral vein over a soft wire and advanced this catheter to the level of the mid-IVC.  Venography was now performed, showing the thrombus related filling defect at the junction of the right atrium.  We now turned our attention to the right neck.  The right internal jugular vein was accessed and a wire was passed to the level of the distal SVC.  The track was dilated and finally a Gore 26 french Dry sheath was passed over a dilator into the right IJ vein and advanced to the level of the SVC.  The sheath was flushed.  The angiovac 24 french balloon tipped drainage cannula was now passed through this sheath under fluroscopic guidance and positioned at the SVC/RA junction.  The balloon was expanded and extra-corporeal venous drainage was initiated.  4 liter/min of flow was obtained.  We advanced the balloon drainage cannula through the right atrium onto the thrombus in the IVC.  Debulking of the clot was successful after several passes.  White (chronic) clot was extracted and observed in the circuit filter.  After 45 minutes of therapy, TEE was used to assess results.  The presenting mobile thrombus at the RA/IVC junction had been removed with unobstructed flow into the right atrium identified.  No further thrombus was seen in the terminal IVC.  Venography was performed, again from the right groin pigtail catheter.  Some minor filling defect remains in the mid IVC, indicative of chronic, adherent thrombus.  This was not retrieved.  Hemodynamics remained stable throughout.
> 
> Under fluroscopic guidance, the drainage and reperfusion cannulas were each removed from the IJ and right CFV, respectively.  Protamine was administered (1/2 dose) and the 26 french sheath was removed from the right IJ.  Direct pressure was applied to both the right IJ and right CFV to endure hemostasis.  The sheaths were removed from the left groin as well and all wounds were covered with sterile dressings.  The patient tolerated the procedure well.  She is extubated within the OR with stable BP and some noticeable bronchospasm which will be addressed with bronchodilator therapy.  Plan is to reassess both venous access sites at 6 hours post-op and begin heparin infusion if able.



I would code this 37187 for the thrombectomy, 36010/75825 for the venogram, 93318 for the TEE.

Thanks,
Jim


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## dlrodrig1 (Mar 4, 2015)

*Angiovac Thrombectomy*

Thank you so much, Jim.


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