# kissing balloon angioplasty/stent



## Shirleybala (Aug 4, 2008)

Hi,
I am  having problem in coding this report thro a same point of access 2 guidewires are inserted and did a kissing ballon angioplasty in both baraciocephalic vein and kept 2 stents if we have to code 2 cath codes 
Please help me to code this.
      The patient's left arm was prepped and draped in the usual sterile
      manner and locally anesthetized with lidocaine.  Preliminary
      ultrasound evaluation was done in the arm, demonstrating patent
      left basilic vein, which was documented.  Under real time
      ultrasound guidance the left basilic vein was accessed with a
      micropuncture set, image recorded.  The access site was dilated
      and 7 French vascular sheath was placed.  Contrast was injected
      and digital subtraction angiography was performed.

      Findings:

      There is high grade stenosis/ virtual occlusion of essentially the
      entire length of the left brachiocephalic vein and a short segment
      of the superior vena cava, just below the confluence of
      brachiocephalic veins.  Selective injection was performed to the
      right brachiocephalic vein, confirming patency.

      The left groin was then prepped and draped in the usual sterile
      manner and locally anesthetized with lidocaine.  The left common
      femoral vein was accessed with a micropuncture set, exchange made
      for a second seven French vascular sheath.  A Berenstein catheter
      and angled glide wire was then successfully advanced into the
      super vena cava, across the high grade stenosis into the right
      brachiocephalic vein.  An exchange was made for a Rosen guide
      wire.  *A second Rosen guidewire was advanced from the left groin
      across the stenosis, right atrium and into the inferior vena cava.*

      After administration of 3000U  IV heparin, Kissing balloon
      angioplasty was performed of the superior vena cava extending into
      both brachiocephalic veins, using 8mm diameter x 8cm long
      balloons.  Angiography performed after balloon dilatation
      demonstrates no improvement.

Subsequently 2 stents were deployed;  a 14 mm x 6 cm extending
      from the SVC to the right brachiocephalic vein and a 14 mm x 8 cm
      long luminex stent extending from the SVC into the left
      brachiocephalic vein.  The stents were post dilated to 10 mm again
      with kissing balloons.  Completion angiography was performed
      demonstrating patency of the stents.  However there still was poor
      flow since the left brachiocephalic vein had not been stented
      peripherally enough.

      The port catheter tip again had to be repositioned, the catheter
      tip was successfully pushed into the left axillary vein with a
      Fogarty balloon.  A second luminex stent was then placed, 12 mm x
      4 cm extending further into the left brachiocephalic vein, just to
      the IJ vein.  This was post-dilated with a 10 mm balloon.  *The
      port catheter tip in the left axillary vein was then snared from
      the groin, and pulled back into the super vena cava.* Completion
      angiography was performed demonstrating improved flow, and patency
      of all 3 stents with contiguous flow of contrast from the left
      axillary vein into the right atrium.

      At the end of the procedure both vascular sheaths were removed and
      hemostasis achieved with manual compression.  The patient
      tolerated the procedure well, left the department in stable
      condition.

Thanks,
Shirley


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## MLS2 (Aug 4, 2008)

this one's a doozie!  I'm thinking an upper extremity venogram (75820/36005) from the basilic vein access.  From the left groin access I got a 36011 for the cath. advancement to the rt. braciocephalic vein, and a 36012 for the lt axillary cath. placement.  It sounds like the SVC (75827) was angioplastied (75978/35476) and that the balloons extended into the braciocephalic veins...I think I would do that as one angioplasty.  2 stents, 75960x2, 37205, 37206.  I was also thinking a 36010 for the placement in the IVC from the 2nd guidewire via the femoral artery (not 100% on that though)
let me know your thoughts on this one


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## Shirleybala (Aug 4, 2008)

*kissing balloon*

Hi,

I have coded like this but i was not yet satisfied so only i left for the clarification.

37205- one stent in rt brachiocephalic vein
37206- additional stent in lt brachiocephalic vein
35476-one angioplasty in rt brachiocephalic vein 
35476-59- one angioplasty in lt brachiocephalic vein
36569- the cath thro the lt basilic vein is then changed to port catheter (snared from groin and placed in SVC) taken as PICC line .
36011-first guide wire to rt brachiocephalic vein thro left common fem vein approach
36011-59- second guide wire to lt brachiocephalic vein thro left common fem vein approach
75978-26- angioplasty S&I
75978-2659- angioplasty S&I
75960-26- Stent S&I
75960-2659- additional stent S&I
75827-2659- SVC gram thro lt basilic vein approach.
Thanks 
Shirley


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## MLS2 (Aug 6, 2008)

Ok after looking at this again... I have 2 stents (75960x2, 37205, 37206) and 2 angioplasties (75978x2, 35476x2 of the braciocephalics).  I have the upper extremity venogram from the basilic vein access (75820/36005)  36011x2 for bilateral braciocephalic veins from the groin access and an SVCgram (75827).  What i'm thinking is that there was the arm access and the leg access and that they met at the IVC for the kissing balloon angioplasties.  I don't see anything about a PICC line though. 
what do you think?  we're getting there


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## Shirleybala (Aug 6, 2008)

Hi,

Basilic vein approach is not used for kissing balloon angioplasty it is used for a separate angioplasty , kissing balloon angioplasty is done by passing 2 guidewires thro the same left groin approach.

The basilic vein catheter is changed in to PICC line in the last paragraph  (snared from the groin and left in SVC)


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## MLS2 (Aug 11, 2008)

your physician's wording is just different from what i'm used to reading...even the interventionalist that I work for was confused on this one
hopefully you got the answers you needed.


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