# Help-stents-cerebral-angios, oh my!



## margaret fahy (Apr 24, 2014)

Hey Learned Friends,
Can someone please give me your opinion on this difficult case.
Thanks so much...Margie
This one is rather difficult...firstly...dr. documents dx. angios, but there was an MRA done immed.prior to this intervention....done due to abnormal findings on CT done earlier in day.  So, I'm thinking I should not do dx angiographies?......then....4 stents placed...report below....
Should it be: 36218-mid.cereb,36217-rica,36216-left vert.?....and then 61635.75894,75898 for the Stents?  They did Stents only and no embo...are the Balloons part of it...nothing separate to code?

Here is the impression of the MRA.

Giant fusiform aneurysm of the distal petrous segment of the
right ICA and giant saccular aneurysm likely arising from the
cavernous segment of the right ICA, as described above. There is
thrombus around both the fusiform and saccular aneurysms. No
evidence of intracranial hemorrhage. There are no abnormalities
in the brain parenchyma and the aneurysms appear long-standing.
Further characterization of details of the neck of the saccular
aneurysm and communication between the fusiform and saccular
aneurysms could be obtained with conventional angiography or CT
angiography.
 These findings were discussed with Dr.  and Dr.  of
neurosurgery by Dr.  at approximately 7:00 p.m., April 19,2014.
REPORT
PROCEDURE: Cerebral Angiogram and Pipeline embolization of right
Internal carotid artery aneurysms

HISTORY: 15 year old male with incidentally found right petrous
and cavernous carotid aneurysms during imaging for head trauma
from soccer ball.

VESSELS SELECTED:
Right common carotid artery
Right internal carotid artery
Left common carotid artery
Let vertebral artery
TECHNIQUE:  
After informed consent the patient was brought into the
angiography suite and placed supine on the angiographic table.
The right groin was prepped and draped using sterile technique.
The skin overlying the right femoral artery was locally
anesthetized with Sensorcaine. Ultrasound guidance was used to
evaluate the right groin site and patency of the right femoral
artery was noted. Using standard micropuncture kit with
ultrasound guidance under realtime visualization the
micropuncture needle was advanced into the right femoral artery.
The right femoral artery was accessed by Dr  and a 6-French
sheath was placed. Using an 0.038" angled Glide Wire and 6-French
Envoy catheter, the bilateral common carotid and left vertebral
arteries were selectively catheterized for angiography.

3-D rotational angiography was performed via right common carotid
injection. Raw data was processed by the interpreting physicians
on a separate Siemens Artis Workstation. Images were rendered
using shaded surface reconstructions and sent the  PACS.

FINDINGS:  
RIGHT COMMON AND INTERNAL CAROTID ARTERY INJECTION, HEAD VIEWS
AND 3-D ROTATIONAL ANGIOGRAM: There is partially thrombosed,
fusiform dilatation of the petrous internal carotid artery
measuring up to 11 mm in diameter. In addition, there is a
saccular, bilobed and partially thrombosed cavernous carotid
aneurysm with very short segment of normal appearing internal
carotid artery in between the two large aneurysms. Otherwise,
unremarkable angiographic appearance of the right supraclinoid
internal carotid artery and right middle cerebral artery. No
evidence of high grade focal intracranial stenosis, or vascular
malformation.
LEFT COMMON CAROTID ARTERY INJECTION, HEAD VIEWS: The patent
anterior communicating artery fills the right anterior cerebral
artery. Unremarkable angiographic appearance of the left
supraclinoid internal carotid artery, left middle cerebral
artery, and left anterior cerebral artery. The angiogram has
normal parenchymal and venous phases. No evidence of cerebral
aneurysm, high grade focal intracranial stenosis, or vascular
malformation.

LEFT VERTEBRAL ARTERY INJECTION, HEAD VIEWS: The right posterior
communicating artery fills the right middle cerebral artery
territory. Unremarkable angiographic appearance of the distal
intracranial left vertebral artery, left posterior inferior
cerebellar artery, vertebrobasilar junction, as well as the
basilar artery and its branches, including the bilateral
posterior cerebral arteries. The angiogram has normal parenchymal
and venous phases. No evidence of high grade focal intracranial
stenosis or vascular malformation.
*****************************************************************
*************************************************
An intervention was performed as follows.
INTERVENTION:
Utilizing a 0.035" Glide Wire, the 6-French Envoy catheter was
navigated into the proximal right internal carotid artery.
Utilizing a Synchro-2 microwire, a 7 x 7mm HyperForm balloon was
navigated into the mid cervical internal carotid artery and
inflated with 50/50 contrast for a balloon occlusion test. The
balloon was kept inflated for 30 minutes, and intermittently
checked for position and to verify continued occlusion of the
internal carotid artery during testing. A focused neurologic
examination of the patient was performed every 1-2 minutes for
the duration of balloon inflation and five minutes post
deflation. Patient tolerated the procedure well without any signs
of neurologic deterioration. The Hyperform Balloon and 6-French
Envoy were removed.  
The 6-French sheath was replaced with a 6-French, 80 cm Shuttle
sheath. Utilizing a 6-French Envoy catheter and 0.035" Glide
wire, the Shuttle Sheath was navigated into the origin of the
right internal carotid artery. Then, using a 0.035" Glide Wire, a
072 Navien catheter was then navigated into the internal carotid
artery at the cervical and petrous junction.  
Utilizing a Synchro-2 microwire, a Marksman microcatheter was
navigated into the right middle cerebral artery. Then a 5 x 25 cm
Pipeline Embolization device was prepped in standard fashion and
deployed from the distal cavernous carotid artery to the
cavernous carotid artery/petrous carotid artery junction,
spanning the cavernous carotid artery aneurysm. Post embolization
angiography demonstrated good apposition of the stent to the
vessel wall and patency of the parent and branch vessels. A
Synchro-2 microwire was then used to navigate the Marksman
catheter into the distal right cavernous carotid artery. Another,
5 x 25 cm Pipeline Embolization device was prepped in standard
fashion and deployed from the mid aspect of the prior stent to
the petrous carotid artery proximal to the area of fusiform
dilatation. Post embolization angiography demonstrated the distal
aspect of the second stent to no longer be telescoped into the
first stent. Instead, the distal aspect of the stent was seen
floating freely in the aneurysmally dilated petrous carotid
artery. Therefore, the Marksman catheter was navigated into the
distal stent and a 5 x 20 cm Pipeline embolization device was
deployed from the mid aspect of the distal stent to the mid
aspect of the proximal stent. Post embolization angiography
re-demonstrated the distal aspect of the second and third stents
to no longer be telescoped in the first stent, and instead
floating freely in the fusiform petrous carotid artery.  
Utilizing a Synchro-2 microwire, a 4 x 11mm Scepter XC balloon
was prepped in standard fashion and navigated into the proximal
stent. The balloon was then inflated with 50/50 contrast until it
was securely apposed against the stent wall. Then, the Scepter XC
balloon catheter was gently pulled in order to reduce the angle
between the free-floating stents and the distal stent in order to
select the distal stent for re-embolization. After the
appropriate angle was obtained, a 300 cm Luge wire was navigated
into the distal right MCA through both stents. With the Luge wire
in place, the balloon was deflated half-way and slowly navigated
into the distal cavernous stent. A Fathom buddy wire was placed
along side the Scepter XC balloon catheter to maintain access.
The balloon catheter was exchanged for a Marathon microcatheter.
A 4.5 x 30 cm Pipeline embolization device was prepped in
standard fashion and then deployed from the distal aspect of the
cavernous carotid stent into the petrous carotid artery proximal
to the site of fusiform dilatation. Post embolization angiography
demonstrated appropriate telescoping of the stents with slow flow
in the saccular cavernous carotid aneurysm and fusiform petrous
carotid aneurysm. The parent and branch arteries were widely
patent on final angiography, otherwise unchanged in appearance in
comparison to pre-embolization imaging.  
At the completion of the procedure, the catheter was removed, and
sheath was sutured in place to be removed later.
No new neurological deficits or complications were encountered
during or immediately following the procedure.  
IMPRESSION

Successful placement of four Pipeline embolization devices from
the petrous to the cavernous right internal carotid artery
resulting in decreased flow within the associated aneurysms. See
details above.
Drs. were present during the whole
procedure and are personally responsible for its interpretation.


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## dpeoples (Apr 24, 2014)

margaret fahy said:


> Hey Learned Friends,
> Can someone please give me your opinion on this difficult case.
> Thanks so much...Margie
> This one is rather difficult...firstly...dr. documents dx. angios, but there was an MRA done immed.prior to this intervention....done due to abnormal findings on CT done earlier in day.  So, I'm thinking I should not do dx angiographies?......then....4 stents placed...report below....
> ...



This is a case where diagnostic angiography was still needed based on the bolded area above. Also, the pipline, even though it is technically a stent, is an embolization device, and should be coded as such. Lastly, multiple pipelines were placed but all in the same operative field, so only one embolizaiton code, but you can bill for the four follow up angiographies (in this scenario). My suggestion:
61624/75894
75898 (x4)
36226 (LV)
36224 (RICA)
36223 (LCCA
76377 for 3d

HTH


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## margaret fahy (Apr 24, 2014)

Dan,
Duh...re the MRA findings...didn't focus in...of course, you're right.
So the angiography codes, and of course, the 3D.
Just looked up the Pipeline, and as you said, it is considered an Embo and not just a Stent.  They refer to it as a Pipeline Embolization.
Once again,  you've outdone yourself.
Your facility is so fortunate to you have there.
Thanks so much.
Margie


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## zoting.arvind@gmail.com (Apr 25, 2014)

can we code the angioplasty code 61630 in the report since the first para of intervention says baloon inflation to reduce the occlusion in the artery....


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## Jim Pawloski (Apr 25, 2014)

zoting.arvind@gmail.com said:


> can we code the angioplasty code 61630 in the report since the first para of intervention says baloon inflation to reduce the occlusion in the artery....



The PTA is part of the embolization.  The stent has to be against the vessel wall to occlude the aneurysm, that why the PTA.

Jim Pawloski, CIRCC


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