# stenting of svc



## superorozco (Mar 30, 2010)

Hi,
I need advice on the following report that I'm stuck on. i appreciate everyone's suggestions.
I have come up with the following codes:
37205
75960.26
35476
75894.26
93531.26
93542
93543
93555.26.59
93556.26.59
DESCRIPTION OF PROCEDURE:  This is a 28-year-old male with a history of
transposition of great vessels status post Mustard procedure done.  The patient was recently admitted and was found to have a superior vena cava baffle obstruction.  Also, patient had some atrial arrhythmias.  For this patient was referred to Dr. J and Dr. P for cardiac catheterization to delineate hemodynamics, as well as to intervene.  Dr. P met with the patient on the day of the procedure and discussed risks and benefits of the procedure.  The risks included, but were not limited to, cardiac or vessel injury causing bleeding requiring blood transfusion and/or emergency surgery, arrhythmia,infection, air or clot embolization causing heart attack or stroke etc.  They understood risks and benefits well.  They asked many appropriate questions.  The consent forms were signed.  The patient was brought to cardiac catheterization lab.  General anesthesia was induced.  Left femoral vein was accessed. Initially a 6-French sheath was placed which was later upsized to 7-French sheath.  The left femoral artery was accessed and a 5-French sheath was placed. Through this catheters and stents were introduced and the procedure was done. At the end of the procedure, catheters and sheaths were pulled out, pressure was held and hemostasis was achieved.  The patient was transferred to recovery area in a good stable condition.  Of note, the patient was also given heparin boluses for the procedure and ACTs were monitored and were kept more than 300.  At the end of the procedure protamine was given.
SATURATION DATA:  Superior vena cava saturation was 74%, with IVC saturation of 76%, and a right ventricle saturation of 71%.  Descending aorta saturation was 100%.
PRESSURE DATA:  IVC pressure was 12/13 with mean of 11, and the AO pressure was 84/54 with mean of 66.  Right ventricle pressure was 24 with end-diastolic pressure of 10.  Superior vena cava pressure was 17/17 with mean of 16. Ascending aorta pressure was 96/58 with mean of 70, and the left ventriclepressure was 106 with end-diastolic pressure of 10-11.  High superior vena cavapressure was 17/18 with mean of 17, and a pullback to inferior vena cava showed mean gradient of 6 mmHg with the IVC pressure of 14/7 with mean of 11.  Post stenting superior vena cava to inferior vena cava pullback showed mean pressure gradient of 1 mmHg with a superior vena cava pressure of 16/13 with mean of 14, and IVC pressure of 15/10 with mean of 13.

ANGIOGRAPHIC RESULTS:
1. First is a systemic venous baffle angiography.  This shows the catheter in
left atrial appendage and contrast draining through the left atrial appendage into the anatomical left ventricle and physiologically right ventricle.
2. Next is a hand injection in the superior vena cava baffle.  This shows the
catheter in a superior vena cava baffle and a significant narrowing at the
ostia of the superior vena cava baffle.
3. Next is an angiography in a superior vena cava baffle.  This shows the
contrast draining through the superior vena cava baffle into the systemic
venous baffle and there is a significant stenoses at the ostia of the
superior vena cava baffle.  Of note, there is also a small PVC vein or a
small pop-off going from this baffle into the pulmonary venous baffle
noted.  This is quite small in size.
4. Next is a high superior vena cava angiography.  This shows the venous pop-
off from superior vena cava draining superior vena cup blood into the IVC,
but this vessel is arising laterally to superior vena cava going
posteriorly and crossing the midline and subsequently draining into the
IVC.
5. Next is an IVC baffle angiographic results.  This shows the IVC baffle
unobstructed lead draining into the systemic venous baffle through the
mitral valve into anatomic left ventricle and physiologic right ventricle.
6. Next is an anatomic right ventricle and physiologically left ventricle
angiography.  This shows the ventricle to be slightly enlarged, but with a
normal function.
7. Next is a hand injection in the innominate vein.  This shows the innominate vein to be patent and draining unobstructed lead to the IVC.  There is also 1 venous pop-off seen in which draining is not very clear on this angiography.
8. Next is a repeat innominate vein angiography.  This shows the innominate
vein patent, as well as the subclavian vein patent, and the venous pop-off
from the neck area draining inferiorly and ending up into the IVC.  A small
branch of it also goes into the coronary sinus.
9. Next 6 are superior vena cava baffle angiography to position the stent.
With the last angiography it was clear the stent is across the narrowing in
the superior vena cava baffle and across the superior vena cava by full
obstruction.
10.Next is a cine documentation of stent deployment into the superior vena
cava baffle.  With this deployment the stent remained in a good stable
position and was fully inflated.
11.Next is a repeat superior vena cava angiography after the stent
implantation.  This shows the narrow area is almost disappeared, as well as
showed the contrast draining unobstructed lead from superior vena cava into
the systemic venous baffle.  Also of note, the previously noted venous pop-
off from the superior vena cava, which was draining inferiorly, is now not
filling and it has forward flow into the superior vena cava.
12.Next is a cine documentation of balloon dilation of deployed stent in the
superior vena cava.  This shows the balloon remained in a stable position
and flared the stent both proximally as well as distally.
13.Next is a repeat superior vena cava angiography which shows the
unobstructed drainage of contrast from the superior vena cava baffle into
the systemic venous baffle.  The narrowest area now measures to be 10.2 mm.
14.Next is a cine documentation of a normal renal collecting system.

DESCRIPTION OF INTERVENTIONAL PROCEDURE:  Description of stent angioplasty of
the superior vena cava baffle.  Berman wedge catheter was placed in the superior vena cava into the innominate vein.  Subsequently through this Amplatz extra stiff wire was advanced and was placed in the innominate vein.  Subsequently the catheter was taken out, as well as the 6-French sheath was taken out, leaving the wire in position.  Subsequently a 7-French sheath was placed over this wire. Once the sheath was in superior vena cava the dilator was taken out leaving the wire in position.  Subsequently over this wire a 29 10 stent was advanced. The stent was placed at the tip of the sheath.  Subsequently the sheath was pulled back and stent was partially exposed.  Multiple angiographies were performed to position the stent.  Subsequently after achieving adequate position of stent the sheath was completely pulled back and last angiography was performed to position the stent.  Subsequently the stent was deployed.  Once the stent was deployed and the balloon was deflated extremely slowly, and the sheath was advanced over this balloon into the superior vena cava.  Once the sheath was in superior vena cava, the balloon was deflated and was taken out.  Repeat angiography was performed which showed the stent is still the narrowest area as the SVC was
dilated.  For this we decided to balloon dilate this stent.  For this we placed Tyshak II 15 mm by 3 cm long balloon.  This balloon was placed across the stent and was slowly inflated.  The stent was seen flaring at both distal and proximal end.  Subsequently the balloon was deflated and in a similar fashion as previously described and the sheath was advanced over the balloon.  Subsequently the balloon was taken out and repeat angiography, as well as pullback was performed, which showed only 1 mm pressure gradient.  Also, the previously noted vein which was having shunt from the superior vena cava baffle into the pulmonary venous baffle was obliterated and was not seen anymore.


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