# TIPS Revision with embolization



## suela923@aol.com (Apr 21, 2014)

Please read and let me know if I coded this correctly.  (I do need to ask the doctor to add his decision to intervene, no prior cath based studies)
36012, 37244, 37183.
Thanks!!

TIPS REVISION

History:

Status post TIPS creation with recurrent esophageal variceal bleeding

Technique:

Risks and benefits of the procedure were discussed with the patient's family and informed consent was obtained. The patient was placed supine on the angiographic table and the right neck was prepped and draped in the usual sterile fashion. The patient had previously been intubated. 2% lidocaine was administered for local anesthesia.

Under direct ultrasound guidance the right internal jugular vein was accessed using micropuncture technique and an Amplatz wire was passed into the IVC. A 10-French vascular sheath was then placed over this wire. A 5-French Berenstein catheter and Glidewire were used to manipulate through the existing TIPS stent into the portal vein. The wire was exchanged for an Amplatz wire and the catheter was exchanged for a 5-French pigtail catheter which was advanced into the splenic vein. Portal and hepatic vein pressures were measured. Digital subtraction venography was then performed in the PA projection. The pigtail catheter was exchanged for a 5-French VS 2 catheter which was used to select a small short gastric vein branch arising from the mid splenic vein. A Renegade high flo microcatheter was then manipulated over a Fathom wire into the proximal aspect of this vein, which was embolized using three 3-2 mm Tornado microcoils as well as a single 2 mm Nester microcoil. The catheter was then removed over an Amplatz wire and a 10 mm x 4 cm angioplasty balloon was advanced into the TIPS stent. Angioplasty of the stent was then performed to a diameter of 10 mm. The pigtail catheter was replaced and repeat digital subtraction venography was performed. Repeat portal and hepatic vein pressure measurements were obtained. The catheter and wire were removed. The sheath was removed and hemostasis was obtained utilizing manual compression. The patient tolerated the procedure well and without immediate complication.

Findings:

Initial portal vein pressure measured 19 mmHg with a hepatic vein pressure of 10 mmHg for a gradient of 9 mmHg.  Digital subtraction portography revealed filling of a small short gastric venous branch with extensive collateralization to gastric varices as well as several large ascending esophageal varices. Additionally, gastric varices arising from the upper pole of the spleen were identified as well as small and likely insignificant gastric varices arising from a larger short gastric vein. Additionally, there appears to be mild stenosis of the proximal aspect of the TIPS stent adjacent to the portal vein access site.

There was successful access and embolization of the short gastric branch extending to the esophageal varices as described above. There was also successful balloon dilation of the existing stent to a total diameter of 10 mm as described above. This results in no significant stenosis of the stent on post procedure portography. Additionally, there was no filling of the esophageal varices identified on postprocedure images with improved hepatopedal blood flow. Post procedure portal vein pressure measured 16 mmHg and hepatic vein pressure measured 12 mmHg for a gradient of 4 mmHg.


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## Jim Pawloski (Apr 21, 2014)

suela923@aol.com said:


> Please read and let me know if I coded this correctly.  (I do need to ask the doctor to add his decision to intervene, no prior cath based studies)
> 36012, 37244, 37183.
> Thanks!!
> 
> ...




I agree with your codes.  

Jim Pawloski, CIRCC


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## suela923@aol.com (Apr 21, 2014)

Thanks Jim, I thought they were correct but was being told that 37241 was a better fit because the doctor didn't dictate the varices were bleeding but I believe what he dictated under History...with recurrent esophageal varceal bleeding...states that.


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## Jim Pawloski (Apr 21, 2014)

suela923@aol.com said:


> Thanks Jim, I thought they were correct but was being told that 37241 was a better fit because the doctor didn't dictate the varices were bleeding but I believe what he dictated under History...with recurrent esophageal varceal bleeding...states that.



That's were I picked up the bleeding diagnosis.  Patient may not have been bleeding at the time of exam, but with the history, I went with the embo for hemmorhage.
Have a great day,
Jim


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