# Iliocaval thrombosis SPECIALTY CODING



## SPECIALTYCODING (Jan 14, 2019)

Please help with coding this procedure.  Your help is really appreciated!!!



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SURGEON:

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ASSISTANT SURGEON:t
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FELLOW:

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PREOPERATIVE DIAGNOSIS:
Iliocaval thrombosis with bilateral lower extremity DVT, history of intracranial hemorrhage and tibial vein DVT and VenaTech convertible filter placement now with venous claudication and severe post thrombotic syndrome.
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POSTOPERATIVE DIAGNOSIS:
Iliocaval thrombosis with bilateral lower extremity DVT, history of intracranial hemorrhage and tibial vein DVT and VenaTech convertible filter placement now with venous claudication and severe post thrombotic syndrome.
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PROCEDURE:
1.	Right IJ ultrasound guided cannulation.
2.	Inferior vena cava filter placement, Cook Celect, via right IJ approach.
3.	VenaTech convertible filter conversion.
4.	Bilateral ultrasound-guided femoral vein cannulation in the midthigh.
5.	Percutaneous venous thrombectomy with the Inari ClotTriever.
6.	Percutaneous venous thrombectomy of the inferior vena cava with Inari flow retriever catheter.
7.	Inferior vena cava angioplasty with kissing 8*mm balloons.
8.	Bilateral iliac and common femoral angioplasty with 8*mm balloon.
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ANESTHESIA:
General.
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COMPLICATIONS:
No immediate complications.
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FLUORO TIME:
64.9 minutes.
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CONTRAST:
180*mL Omnipaque.
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INDICATION FOR PROCEDURE:
Ms. Cole is a 65-year-old female who developed a pulmonary embolism at the end of 09/2018.  After this she was started on Xarelto.  Approximately 1*week later she presented to Greenville Memorial with an acute intracranial hemorrhage.  She was taken off anticoagulation and a lower extremity venous duplex was done which showed a right tibial DVT.  Because of her contraindication to anticoagulation with a recent head bleed, a VenaTech convertible filter was then placed a few days later.  After discharge, she began having bilateral lower extremity swelling and pain and discomfort and presented to the ER multiple times.  During her workup she was found to have bilateral extensive DVT in both extremities up into the iliac veins.  She was referred back to see us and at that time she had severe post thrombotic syndrome with swelling and weeping from the lower legs as well as severe venous claudication right greater than left.  A CT venous phase of the abdomen and pelvis was performed which showed thrombus from just above the filter down both iliac veins and occlusion of her inferior vena cava, iliac veins and femoral veins.  I contacted neurology to discuss her risk of repeat intracranial hemorrhage on anticoagulation and since she was approximately 2-1/2 to 3 months out, her risk was slightly lower but still significant.  We elected that if she wanted anticoagulation to help improve her symptoms that controlled monitoring with Coumadin and heparin would be the best option.  The risks and benefits and alternatives for percutaneous venous thrombectomy and anticoagulation were discussed in length with the patient including significant risk of rebleed and she consented to the procedure.
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DESCRIPTION OF PROCEDURE:
Patient was brought to the Endo suite and placed in supine position.  The right neck and bilateral groins and thighs were prepped and draped in usual sterile fashion.  Using ultrasound guidance the right IJ was cannulated and a wire and sheath were taken down.  The tract was serially dilated and a venogram was performed.  This showed that the inferior vena cava above the filter was widely patent without thrombus.  Bilateral renal veins were patent as well and the suprarenal IVC was patent.  At this point we took a Cook Celect retrievable filter and placed it in the infrarenal IVC just above the previous VenaTech filter.  We then turned our attention to both groins and thighs and performed ultrasound and cannulation of bilateral femoral veins in the midthigh.  We then serially dilated the tracts and then placed a 13-French sheath for the clot retriever.  At this time we took a wire and catheter up and over and snared this to have through-and-through wire access.  We then performed multiple passes with the percutaneous thrombectomy device and had extraction of a large amount of thrombus.  We then repeated this from the left side.  Dr. Carsten performed thrombectomy on the left.  We then performed a venogram which showed improvement of flow through the iliac veins but continued occlusion of the inferior vena cava.  We then sent our wire cephalad into the inferior vena cava and crossed the thrombus here.  Then using the flow device we performed serial percutaneous venous thrombectomy of the inferior vena cava after upsizing our sheath.  We also used our sheath to aspirate the clot.  Completion angiography showed still some clot in the filter.  We then fully deployed our Cook Celect filter.  We then took a snare down and removed the top cap of the VenaTech convertible filter.  Because of the clot around the filter the struts did not fully deploy to the stent therefore we performed venous angioplasty here with kissing 8*mm balloons to convert it fully to a stent.  We then performed serial angioplasty down the IVC to macerate the clot and perform aspiration thrombectomy once again.  We had adequate success.  We then performed serial angioplasty of the IVC and bilateral common, external iliac veins as well as common femoral vein.  Completion venography from both femoral veins showed good flow through the femoral veins into the iliac veins and inferior vena cava.  There was still a small amount of clot lining the walls of the inferior vena cava but there was brisk flow throughout.  At this point the right neck sheath was removed and pressure was held until there was good hemostasis and bilateral femoral vein sheaths were removed and a U-stitch was placed at pressure was held until there was good hemostasis.  The patient was extubated and following commands and transferred to the postoperative unit in stable condition on a heparin drip.
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IMPRESSION:
1.	Successful inferior vena cava filter placement.
2.	Successful conversion of VenaTech convertible filter.
3.	Successful percutaneous venous thrombectomy of the inferior vena cava, bilateral common and external iliac veins, common femoral and femoral vein.
4.	Successful venous angioplasty of the inferior vena cava, common iliac and external iliac veins as well as common femoral vein.
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My codes:
37187 50
37187 59 IVC
37248 50
37248 IVC
37249 50
37191
36012 50

Thank you,
Diana
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## jadhavganesh345@gmail.com (Jan 30, 2019)

37191
37187-50
36010-50
we can't code angioplasty when perfomed to macerate the clot along with thrombectomy
"Need medical necessity to perform angioplasty of *IVC and bilateral common, external iliac veins as well as common femoral vein.  If stenosis the shold know whether it is contiguous or separate
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Don’t code venography as diagnosis is already established





Thank You,
Ganpati Jadhav
CIRCC CPC


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## SPECIALTYCODING (Feb 2, 2019)

jadhavganesh345@gmail.com

Oh, I was way off on this one. Thanks for taking the time to review.

Diana CPC, COC


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