# Thrombolytic Therapy for DVT (6 day treatment)



## birky (Dec 7, 2010)

Can anyone help with the following?

*Day #1* SERVICES PROVIDED 1. Left Lower extremity venogram. 2. Initiation of thrombolytic therapy using catheter- directed TPA. 3. Intravenous moderate sedation. 4.

Ultrasound guidance for venous access.


PROCEDURE/METHODS:
The procedure was explained in detail to the patient. Potential risks, benefits and alternative therapies were discussed.

All questions were answered and informed consent was obtained.

The patient's left lower extremity was examined with ultrasound showing patency of the left common femoral vein, thrombosis of the left popliteal vein.

The patient's left groin was sterilely scrubbed, prepped and draped in the standard fashion. Local anesthetic was applied using 2% Xylocaine. Using ultrasound guidance and a micropuncture needle, access was gained into the left common femoral vein. Ultrasound was used to visualize the needle entering into the lumen of the vessel. The percutaneous access was dilated to accept a 6-French introducer sheath. Limited venogram was performed of the common iliac vein identifying the femoral vein and popliteal vein. Using an angled glidewire and catheter, access was gained into the femoral vein. A selective venogram of the femoral vein was performed showing extensive thrombus up to the origin of the common femoral vein. Catheter and wire were guided fluoroscopically down the femoral vein and into the popliteal vein.

Repeat venogram was obtained showing thrombosis of the popliteal vein.

The catheter was removed over a wire and replaced with a 4-French multiple sidehole infusion catheter which was positioned within the popliteal and distal femoral vein. Thrombolytic therapy was then started at 0.48 mg/hour of TPA at a concentration of 4 mg TPA within 1000 mL of 0.9 normal saline. The catheters and wires were secured in position.

The patient transferred to the medical ICU for overnight observation.


FINDINGS:
The ultrasound and venogram shows extensive acute thrombosis of the deep venous system in the left lower extremity from the popliteal vein up to and near the confluence of the common femoral vein.

The catheter with multiple sideholes is positioned to deliver thrombolytic therapy within the thrombus as described.

IMPRESSION 1.

EXTENSIVE ACUTE DEEP VEIN THROMBOSIS INVOLVING THE LEFT FEMORAL VEIN AND POPLITEAL VEIN.

2.

INITIATION OF THROMBOLYTIC THERAPY USING CATHETER- DIRECTED LOW DOSE TPA FROM AN ANTEGRADE LEFT COMMON FEMORAL VEIN APPROACH.




*Day #2:* SERVICES PROVIDED 1. Selective left leg venogram. 2. Catheter exchange during thrombolytic therapy. 3.

Intravenous moderate sedation.


PROCEDURE/METHODS:
IV moderate sedation was used during the procedure using IV Versed and Fentanyl. The patient was monitored with automatic blood pressure cuff measurement, EKG and pulse oximetry throughout the procedure. Medications were administered by an RN.

The patient received 1 mg of Versed and 50 mcg of Fentanyl throughout the procedure.

The patient's right groin preexisting catheters were sterilely scrubbed, prepped and draped in standard fashion. A limited venogram was performed through the preexisting catheter of the left lower extremity.

The 4- French multiple sidehole infusion catheter was removed over a 0.035 wire and replaced with a 5-French multiple sidehole infusion catheter with 40 cm in infusion length.

A coaxial 3-French catheter was passed through the 5- French catheter and guided into the tibioperoneal trunk. A limited venogram of the tibial vein was performed.

The catheter was positioned to optimize delivery of thrombolytic therapy to residual thrombus.


FINDINGS:
The repeat venogram of the left lower extremity shows some improvement in lysis of the distal popliteal and femoral vein.

There is complete occlusion of the more proximal femoral vein.

The catheters were exchanged and repositioned to optimize delivery to the persistent thrombus within the SFA and popliteal vein, as well as delivery of TPA to the tibioperoneal trunk.

IMPRESSION 1.

REPEAT VENOGRAM SHOWING SOME IMPROVEMENT IN LYSIS OF THE EXTENSIVE LEFT LOWER EXTREMITY DVT COMPARED TO FILMS OBTAINED 24 HOURS EARLIER.

2.

CATHETER EXCHANGE AND REPOSITIONED TO OPTIMIZED DELIVERY OF THROMBOLYTIC THERAPY TO RESIDUAL CLOT.



*Day #3* SERVICES PROVIDED:
1. Left leg venogram during thrombolytic therapy. 2. Mechanical thrombolysis using AngioJet left leg venous DVT. 3. Venous angioplasty. 4.

Intravenous moderate sedation.


CONTRAST:
65 mL Omnipaque 300.

BAP:
1108 cGy cm2.


COMPARISON:
10/13/2010 


PROCEDURE/METHODS:
IV moderate sedation was given throughout the procedure using IV Versed and fentanyl. The patient was monitored with automatic blood pressure cuff measurement, EKG, and pulse oximetry during the procedure.

Medications were administered by an RN.

Patient's left groin and preexisting catheters are sterilely scrubbed, prepped and draped in the standard fashion. Limited venogram of the left lower extremity was performed through the preexisting catheters. The catheters were removed and the left femoral vein and popliteal vein were mechanically declotted using the AngioJet thrombectomy device. Repeat venogram was performed, after which the popliteal and femoral vein was angioplastied with an 8-mm balloon.

Postangioplasty venography was obtained.

A new 5-French multiple sidehole infusion catheter was positioned across the left femoral vein and popliteal vein. A coaxial 3-French catheter was passed through the 5-French catheter and guided into the left calf within the posterior tibial vein. Thrombolytic therapy was restarted and doses divided between the infusion catheter and the coaxial microcatheter.

The patient was transferred back to the ICU for overnight observation.


FINDINGS:
Following an additional 24 hours of thrombolytic therapy using catheter-directed low-dose tPA, repeat venogram was performed showing some improvement in lysis of the extensive left lower extremity DVT.

Following mechanical thrombectomy with the AngioJet, there is marked improvement in flow and venographic appearance of the extensive left leg DVT.

Following angioplasty, there was still improved flow with two focal areas of high-grade stenosis possibly representing old occlusion/webs.

IMPRESSION 1.

MECHANICAL THROMBOLYSIS OF AN EXTENSIVE LEFT LEG DVT USING ANGIOJET SYSTEM WITH CONTINUATION OF THROMBOLYTIC THERAPY.

2.

MARKED IMPROVEMENT IN ANGIOGRAPHIC APPEARANCE OF THE LEFT LEG DVT FOLLOWING CHEMICAL AND MECHANICAL THROMBOLYSIS.

3.

5FR CATHETER AND COAXIAL 3 FR INFUSION MICROCATHETER REPOSITIONED TO OPTIMIZE DELIVER OF TPA TO RESIDUAL THROMBUS.



*Day #4:*  SERVICES PROVIDED:
1. Left leg venogram during thrombolytic therapy. 2. Vein angioplasty. 3. Catheter exchange during thrombolytic therapy. 4.

Intravenous moderate sedation.


PROCEDURE/METHODS:
Following 4 days of thrombolytic therapy using catheter-directed low-dose TPA for an extensive left leg DVT, a repeat venogram was performed through preexisting catheters and wires.

Catheters and wires were then removed over a 0.035 wire and the 

tibioperoneal trunk was then angioplastied with a 4-mm balloon. The popliteal vein was angioplastied with a 6- mm balloon.

Postangioplasty venography was performed.

A new multiple sidehole 5-French catheter and coaxial 3- French catheter were positioned to optimize delivery of TPA through residual thrombus within the popliteal, distal SFA, and the tibioperoneal trunk.


FINDINGS:
Following 4 days of thrombolytic therapy, a repeat venogram shows near complete lysis of all the clot within the femoral vein and common femoral vein. Residual thrombus within the popliteal vein and the tibioperoneal trunk was noted. Following angioplasty and repeat venogram, there is improved flow from the tibial veins through the popliteal vein to the femoral vein.

The new catheter and coaxial 3-French catheter were positioned to optimize delivery of TPA to the residual thrombus within the tibioperoneal trunk and the popliteal vein.

IMPRESSION 1.

MARKED IMPROVEMENT IN LYSIS OF AN EXTENSIVE LEFT LEG DVT FOLLOWING ADDITIONAL 24 HOURS OF THROMBOLYTIC THERAPY USING CATHETER-DIRECTED LOW-DOSE TPA.

2.

RESIDUAL OCCLUSION OF POPLITEAL AND TIBIAL VEIN ANGIOPLASTIED AS DESCRIBED.

3.

CATHETER REPOSITIONING TO OPTIMIZE DELIVERY OF TPA INTO RESIDUAL THROMBUS WITHIN THE TIBIOPERONEAL TRUNK AND THE POPLITEAL VEIN.




*Day #5*: SERVICES PROVIDED:
1. Left leg venogram during thrombolytic therapy. 2. Mechanical thrombolysis using AngioJet. 3. Vein angioplasty. 4.

Intravenous moderate sedation.

DAP:
351 cGy cm2 


FLUORO TIME:
6 minutes 31 seconds.


COMPARISON:
10/16/2010 


PROCEDURE/METHODS:
Following 5 days of thrombolytic therapy, a repeat venogram of the left leg was performed through preexisting catheters. The patient was given IV moderate sedation throughout the procedure using IV Versed and fentanyl. The patient was monitored with automatic blood pressure cuff measurement, EKG, and pulse oximetry during the procedure.

Medications were administered by an RN.

The patient's left groin and preexisting catheters were sterilely scrubbed, prepped and draped in the standard fashion. A small amount of contrast was injected through the previous catheters and a left leg venogram was performed. The catheters were then removed and replaced with a 6-French expedier AngioJet mechanical thrombectomy catheter. The catheter was used to mechanically thrombectomize the residual clot seen within the popliteal vein. Post mechanical thrombectomy, a venogram was performed after which a focal smooth narrowing of the popliteal vein was angioplasties with a 6-mm balloon. The balloon was semi-complaint and expanded to 6.88 mm in diameter. Postangioplasty shows residual smooth narrowing of the popliteal vein.

No significant residual thrombus within the popliteal or femoral vein noted.

The catheters were then removed. The sheath was scheduled to be removed approximately 2 hours after discontinuation of heparin and TPA. Heparin was to be restarted through a peripheral IV 2 hours after hemostasis achieved at the left groin.

SCDs were ordered for the left calf to improve blood flow through the deep venous system.

IMPRESSION 1.

COMPLETE LYSIS OF THE EXTENSIVE DVT INVOLVING THE 

LEFT LOWER EXTREMITY FROM THE COMMON FEMORAL DOWN TO AND INCLUDING THE POPLITEAL VEINS.

2. PERSISTENT SMOOTH NARROWING INVOLVING THE MID POPLITEAL VEIN SUSPECTED TO BE EXTRINSIC COMPRESSION.

THE FOCAL NARROWING WAS RESISTANT TO ANGIOPLASTY.

3.

PATIENT RECOMMENDED CONVERSION FROM IV HEPARIN TO ORAL COUMADIN WITH BRIDGING AND CONTINUATION OF ORAL ANTICOAGULATE FOR AT LEAST 1 YEAR IF NOT LIFETIME.


I know this is alot and any help is greatly appreciated.


----------



## kbazarte@yahoo.com (Dec 7, 2010)

DAY 1:

Uni Veno gram 75820

cath selects femoral vein 36012, popliteal vien 36012-59

infusion tx 37201, 75896

DAY 2:

cath exchange 37209, 75900
fu venogram 75898

DAY 3:

fu veno 75898
cath exchange 37209, 75900
mechanical trhombectomy 37188
pta popliteal 35476, 75978
pta femoral vien 65476-59, 75978-59

DAY 4:

fu veno 75898
cath exchange 37209, 75900
pta tibioperoneal trunk 35476, 75978
pta popliteal 35476-59, 75978-59

DAY 5:

fu veno 75898
mechanical thrombectomy 37188
pta popliteal ven 35476, 75978


----------



## birky (Dec 8, 2010)

Cannot thank you enough for the help


----------



## dpeoples (Dec 13, 2010)

birky said:


> Can anyone help with the following?
> 
> *Day #1* SERVICES PROVIDED 1. Left Lower extremity venogram. 2. Initiation of thrombolytic therapy using catheter- directed TPA. 3. Intravenous moderate sedation. 4.
> 
> ...




ok here goes:
first of all I only see 5 days and coded accordingly
day 1
36011/75820 (left common femoral access advanced 1order to lt pop)
37201/75896

day 2
37209/75900
75898

day 3
37187
75898
37209/75900

day 4
37188
75898
37209/75900

day5
37188
75898
therapy ended.

HTH


----------



## birky (Dec 14, 2010)

Thank you so much, I really appreciate it.


----------

