# Perq thrombectomy - primary or 2ndary?



## stgregor (Aug 3, 2008)

I apologize in advance for the length, but I am having a bit of trouble determining whether the thrombectomy procedures described within the op report below are primary or secondary. Since 37186 cannot be coded with 37184 or 37185, how should this case be coded? (Only concerned about the thrombectomy coding; the rest I have down.) Thanks in advance to anyone who is willing to assist! 

CPT 2008 states: "Primary mechanical thrombectomy may precede or follow another percutaneous intervention. Most commonly primary mechanical thrombectomy will precede another percutaneous intervention with the decision regarding the need for other services not made until after mechanical thrombectomy has been performed. Occasionally the performance of primary mechanical thrombectomy may follow another percutaneous intervention. Arterial mechanical thrombectomy is considered a "secondary" transcatheter procedure for removal or retrieval of short segments of thrombus or embolus when performed either before or after another percutaneous intervention (eg, percutaneous transluminal balloon angioplasty, stent placement). Secondary mechanical thrombectomy is reported using 37186. Do NOT report 37186 in conjunction with 37184–37185." 

PROCEDURE: 
1. Selective contralateral right femoral arteriograms with lower extremity angiograms. 
2. Complex Frontrunner recanalization of chronically occluded right femoral-to-popliteal bypass graft. 
3. Percutaneous transluminal angioplasty, right femoral-to popliteal bypass graft. 
4. Primary Rheolytic mechanical thrombectomy, right femoral-to popliteal bypass graft. 
5. Percutaneous self-expanding stent implants, proximal and distal right femoral-to-popliteal bypass graft. 
6. Rescue Rheolytic thrombectomy, right anterior and posterior tibial arteries. 
7. Catheter exchange for administration of subselective catheter thrombolysis with placement of an EKOS thrombolytic infusion catheter system. 
8. Initiation of subselective intraarterial thrombolysis to the right femoral-to-popliteal bypass graft via the EKOS thrombolytic infusion catheter system. 

PROCEDURE: A 7-French sheath was placed into the left common femoral artery retrograde. The contralateral right femoral artery was accessed from the left femoral approach using a 4-French Cobra C1 diagnostic catheter and an angled Glidewire. The angled Glidewire was withdrawn and a 0.035 Supracore guidewire was substituted, and the diagnostic catheter and left 
femoral sheath were withdrawn and a 7-French 45-cm length Pinnacle Destination sheath was substituted and advanced to the right common femoral artery from the left femoral approach over the Supracore guidewire. 
After guiding sheath placement, initial anticoagulation was achieved with low-dose intravenous heparin at a dose of 3000 units. The chronic total occlusion of the right femoral-to-popliteal bypass graft of 7 years' duration was crossed with difficulty, but ultimately with success using a Frontrunner XP device with a MicroGuide. 
After crossing the total occlusion, a Spartacore guidewire was advanced through the MicroGuide catheter into the distal anterior tibial artery. Balloon angioplasty of the proximal and distal anastomoses was then performed with a 4 mm x 2 cm Sterling balloon to 12 atmospheres of pressure. 
Following this, a 6-mm Emboshield was deployed into the distal right popliteal artery with use of an exchange length extra-support Emboshield wire. 
After deployment of the Emboshield, Rheolytic mechanical thrombectomy of the bypass graft was then performed using the 6-French Expedior. A primary rheolytic thrombectomy of the occluded right femoral-to-popliteal bypass graft was then performed using a 6-French Expedior AngioJet catheter. Two passes were made with the device. 
Follow-up angiography showed a trickle flow through the graft but without significant residual thrombus. The trickle flow was related to the presence of severe subocclusive lesions at the proximal and distal anastomoses of the bypass graft. A decision was therefore made to proceed with further angioplasty using a 6-mm mm Sterling balloon at 16 atmospheres of pressure at the proximal and distal anastomoses. 
Following balloon angioplasty, flow was restored in the graft, but severe residual stenoses of 90% were noted proximal and distal due to intimal disruption and elastic recoil which were both felt to be in need of adjunctive stent implants. 
The distal anastomosis was stented first with a 7 mm x 39 mm Boston Scientific Sentinel stent spanning the distal anastomosis into the native right popliteal artery. The proximal anastomosis was then stented using a 7 mm x 20 mm Boston Scientific Sentinel stent. Both stents were then post-dilated using a 6-mm Sterling balloon to l6 atmospheres of pressure. Follow-up angiography showed excellent results on the bypass graft with residual stenoses of generally 0-10% throughout. There were no residual filling defects in the graft to suggest residual thrombus. 

Secondary rescue Rheolytic thrombectomy was therefore performed of both the anterior and posterior tibial arteries using an XMI AngioJet catheter placed both into the distal anterior and posterior tibial arteries to the level of the ankle each. 
Follow-up angiography showed improved flow, although still sluggish at the ankles, probably due to small distal clot embolization. A decision was therefore made to place an EKOS thrombolytic infusion catheter into the right femoral-to-popliteal bypass graft to perform subselective intraarterial thrombolysis overnight. Thrombolysis was initiated in the Angiographic Suite with a Retavase infusion at an initial rate of 0.25 units per hour with a plan for repeat arteriography within 24 hours. 
There were no procedural complications other than the notation of distal thromboemboli. 

CONCLUSIONS: 
1. Status post contralateral right femoral catheter placement from the left femoral approach with selective right femoral and lower extremity arteriography, which demonstrated a chronic occlusion of the right femoral-to-popliteal bypass graft with good reconstitution at the level of the popliteal artery. 
2. Status post very complex but successful Frontrunner recanalization of the chronically occluded right femoral-to-popliteal bypass graft. 
3. Status post primary Rheolytic mechanical thrombectomy of the right femoral-to-popliteal bypass graft with extraction of the chronic thrombus of the graft. 
4. Suboptimal result following percutaneous transluminal angioplasty of the proximal and distal anastomoses of the bypass graft due to elastic recoil and intimal disruption, necessitating adjunctive self-expanding stent implants. 
5. Status post successful proximal and distal femoral-to-popliteal bypass graft anastomoses self-expanding stent implants using two 7-mm diameter Boston Scientific Sentinel stents and a maximum of a 6-mm balloon for post stent dilatation proximal and distal with residual stenoses of 0-10% throughout. 
6. Procedure complicated by distal thromboemboli to the anterior 
and posterior tibial arteries despite the use of distal embolic protection, with an Emboshield catheter in the popliteal artery necessitating rescue Rheolytic mechanical thrombectomy and adjunctive subselective intraarterial thrombolysis to the right anterior and posterior tibial arteries as outlined above. 
7. No further complications.


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## Shirleybala (Aug 4, 2008)

Hi,

We have to code only the secondary thrombectomy.

If we coded primary and secondary i think it will get denied.

I also asked to my friend.

Thanks
Shirley


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