# Transarterial Chemoembolization of the Liver



## chembree (Jul 3, 2012)

CLINICAL HISTORY: 58-year-old female diagnosed in 2009 with colon
   carcinoma. In 2010 hepatic metastatic lesions were treated with RFA.
   Recent rise in CEA and PET scan evaluation showing multiple
   hypermetabolic left and right hepatic masses. Patient's oncologist Dr.
   Jones requested regional chemotherapy drug eluting bead embolization for
   palliation.  No extrahepatic metastatic disease.

   PROCEDURE: Informed consent was obtained. A preprocedural pause was
   performed.

   MAC anesthesia was provided by anesthesia department.

   The right groin was prepped and draped in the usual sterile fashion. 1%
   lidocaine was used as a local anesthetic.

   Ultrasound guided puncture of the right common femoral artery was
   performed with an 18-gauge arterial needle followed by guidewire over
   which there was placement of a 5 French angiographic sheath. There is
   ultrasound documentation of needle entry within the right common femoral
   artery with images sent to PACs.

   Pigtail catheter was initially utilized for abdominal aortogram placed
   over a guidewire. After abdominal aortogram superior mesenteric artery
   was slightly catheterized with a 5 French Mickelson catheter. This
   catheter was also utilized to catheterize metastatic access. Next the
   Mickelson catheter was exchanged over a guidewire using a 5 French Cobra
   catheter an attempt to catheterize the mesenteric artery. This proved
   unsuccessful and a Simmons one catheter was successful to allow
   successful purchase into the right right common hepatic artery. This
   allowed placement of a microcatheter 2.2 French in size which was used
   for selective catheterization to the left hepatic artery and sub and
   subsequently the right hepatic artery and then finally into the branch
   of the right hepatic artery feeding segments 8 and 7.

   Chemotherapeutic agent Adriamycin 50 mg was admixed with sterile saline
   to reconstitute 30 to 60 micron sized Quadraspheres embolic agent. 
   Supernatent excess fluid was removed after the soaked spheres settled. 
   The Quadraspheres were then admixed with 10 ml of Isovue 300 contrast. 

   With the Renegade 2.2 french  microcatheter parked in the left hepatic
   artery chemotherapy embolization was performed delivering  7 aliquots 1
   mL each under careful fluoroscopic control using the Adriamycin soaked
   Quadraspheres now 120-240 micron in size as the embolic agent.  This
   delivered approximately 50,000 beads and 13 mg of Adriamycin to the left
   lobe.

   With the microcatheter heart in the right hepatic artery chemotherapy
   therapy embolization was performed delivering 6 aliquots1 ml each under
   careful fluoroscopic control using the Adriamycin Quadraspheres 120-240
   micron in size as the embolic agent. This delivered approximately 50,000
   beads and 12 mg of Adriamycin to the segment 7 and a portion of segment
   8 right hepatic lobe.

   Hemostasis was obtained at the right groin puncture site excellent
   hemostasis and no change in the right dorsalis pedis pulse compared to
   the preprocedural pulse.

   There are no immediate complications.

   Total contrast load was 172mL Isovue-300.

   Fluoroscopic time: 32.7 minutes.

   FINDINGS: Abdominal aortogram: The aorta is not aneurysmal. There are
   single unremarkable bilateral renal arteries. There is patency of the
   celiac axis and SMA as well as IMA noted. 

   Superior mesenteric arteriogram: There is normal appearance to the
   proximal intestinal arcade. The supramesenteric vein and portal vein are
   patent.

   Celiac arteriogram: There is rapid patency of the splenic artery, the
   common hepatic artery, gastroduodenal artery and left and right hepatic
   arteries. There is normal arterial anatomy to the left hepatic artery
   and right hepatic artery. The gastroduodenal artery arises at the
   bifurcation of the proper hepatic artery. Mild hypervascularity and
   identifiable neovascularity is seen in association with the mottled
   parenchymal opacification to correlate with multiple moderately-sized
   masses within the left lobe and right lobe arterial distributions.
   Notably present is the moderately-sized lesion in the far periphery left
   hepatic lobe, the superior aspect left hepatic lobe smaller lesion in
   addition to a grouping of nodules in the right hepatic dome and moderate
   sized nodules within the medial right lobe and a notable nodule in the
   inferior posterior right hepatic lobe.

   Selective proper hepatic arteriogram: There is better demonstration to
   the left and right hepatic arteries and their parenchymal distributions
   as described in the celiac arteriogram. There is better opacification
   and detail of the neovascularity.

   Selective left hepatic arteriogram: There is early bifurcation of the
   left hepatic artery. The left hepatic superior nodule in segment 2 and
   far lateral left hepatic nodule segment 3 are demonstrated.  Normal
   hepatic arterial anatomy. Left and right neoplastic changes of
   moderately-sized metastatic deposits.

   Followup embolization selective left hepatic arteriogram: There is
   sluggish transit of contrast as expected status post embolization of the
   left hepatic artery distribution. There is staining of the near stagnant
   contrast identified in the periphery of the left lobe superiorly.

   Selective right hepatic arteriogram: Arborization is present seen to
   feed the collection of nodularity within the right hepatic dome.,
   segment 7 and 8  There is a prominent parenchymal stain seen in
   association with the moderately large medial right hepatic segment 5 and
   inferior posterior segment 6 right hepatic masses.

   Followup embolization subselective right hepatic arteriogram:  Segment 8
   and possibly a portion of segment 7 shows sluggish flow and  staining to
   the 2-3 nodules within the superior aspect of the right hepatic dome.


   CONCLUSION: Conservative and selective chemoembolization to the left
   hepatic lobe and superselective conservative immobilization to segment 8
   and a portion of segment 7 right hepatic lobe.

   FOLLOW-UP: Patient will be admitted for overnight observation and pain
   control with medications to counteract any symptoms of postembolization
   syndrome. Post focal followup is planned. In 34 weeks' time systemic
   chemotherapy could be initiated versus consideration for further
   chemotherapy embolization to the right hepatic lobe.  

   Thank you for referring patient to Interventional Radiology for their
   procedure and allowing me to participate with you in their care.

Can someone please help me code this chart? I have an attempt listed below. I have not added any modifiers at this point. 

76937 Ultrasound guided
36245 superior mesenteric artery slightly catheterized 
36247 catheterization to the left hepatic artery 
36248 right hepatic artery
? 36248 branch of the right hepatic artery feeding segments 8 and 7
? 96420 Chemotherapeutic agent
37204 chemoembolization 
75894 chemoembolization S&I
75726 Superior mesenteric arteriogram
75726 Celiac arteriogram
75774 Selective left hepatic arteriogram
75774 Selective proper hepatic arteriogram
75898 Followup embolization selective left hepatic arteriogram
75774 Selective right hepatic arteriogram


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## jmcpolin (Jul 3, 2012)

you can also bill 79445, I am thinking no on the 96420.


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## MLS2 (Jul 5, 2012)

No on the 96420.  I would do 36247 for the left hepatic and one 36248 for the branch furtherest out off the right hepatic.  
hope that helps


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## Jim Pawloski (Jul 5, 2012)

MLS2 said:


> No on the 96420.  I would do 36247 for the left hepatic and one 36248 for the branch furtherest out off the right hepatic.
> hope that helps



96420 is a yes to code.  It is used for handling and injecting the chemo agent.  I agree with the catheter codes.
Jim Pawloski, CIRCC, R.T. (CV)


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