# Transcath embo proc -- need assurances



## Rita Bartholomew (May 13, 2011)

_Newbie to IR, but just ret'd from Dr. Z's conference in Boston.  I think these codes are right, but don't have confidence to commit._

PREOPERATIVE DIAGNOSIS:  Endoleak after endovascular abdominal aortic aneurysm repair with interval expansion of the abdominal aortic aneurysm sac. 

POSTOPERATIVE DIAGNOSIS:  Type 2 endoleak after endovascular aortic aneurysm repair.  

NAME OF PROCEDURES: 
Angiogram of the abdominal aorta and bilateral lower extremity.  
Selective catheterization of the superior mesenteric artery.  
Selective catheterization of a branch of the superior mesenteric artery.  
Additional images, left lower extremity. 
Selective catheterization of 2 branches of the left hypogastric artery. 
Endovascular coiling of 2 branches of the left hypogastric artery, contributing to endoleak.  
Selective catheterization of the right hypogastric artery. 
Additional images, superior mesenteric artery.  

SURGEON:  XXXXXXXXXX

COMPLICATIONS:  None. 

ACCESS:  5 French sheath, left common femoral artery.  

RADIOLOGIC FINDINGS: 
The abdominal aorta was patent with solitary renal arteries bilaterally.  The right renal artery was at a higher level than the left. 
An endovascular device was present in the infrarenal abdominal aorta, consistent with prior stent graft.  This appeared to be an Endologix power link device.  The device came to within 3 mm of the left renal artery.  

The left kidney appeared to be small with a diminished left nephrogram noted.  With flush abdominal aortogram, no early endoleak was noted on the right side, a large lumbar artery entered near the neck of the aneurysm.  The source of this lumbar artery was not clearly defined.  This entered the high aneurysm sac and a type 2 endoleak was noted which was small.  In the later pictures, lumbar arteries arising from the left hypogastric were noted to come toward the aneurysm sac as well.  

Images from within the device itself showed no evidence of endoleak early on, although branches arising from the left hypogastric artery appeared to direct toward the abdominal aneurysm sac.  Two major branches of the hypogastric artery appeared to be responsible.  No significant branching appeared to be coming from the right hypogastric artery.  

The right and left hypogastric arteries were somewhat tortuous.  There was some stenosis of the right hypogastric artery near its origin which did not appear to be hemodynamically significant.  

Selective catheterization of the superior mesenteric artery failed to identify branches entering into the high right abdominal aneurysm, however, a single branch radiated directly toward the left side of the abdomen, and then caudad and then toward the abdominal aneurysm sac and was concerning for a side branch causing an endoleak.  Further supra-selective catheterization of this branch showed that it did not enter the aneurysm sac and was a mesenteric artery.  

Selective catheterization of the right hypogastric artery showed no significant branches radiating towards the aneurysm sac.  Selective catheterization of the left hypogastric artery showed 2 branches radiating toward the aneurysm sac.  I was able to selectively catheterize 1 of these 2 branches which then bifurcated, and both branches of this artery leading directly into the anterior aneurysm sac were successfully coiled with micro-coils. 

Another branch was present near the origin of the hypogastric artery, also radiating craniad and toward the aneurysm sac.  I was unable to selectively catheterize this branch.  Numerous different catheters and wires were attempted.  I accepted this result.  No Angio-Seal was used and no ultrasound guidance was used for access.  There were no complications. 

DESCRIPTION OF PROCEDURE:  The patient was taken to the Cardiac catheterization Laboratory where he was placed on the table in a dorsal recumbent position.  After excellent moderate sedation, the skin of the groin areas was prepped and draped in a standard sterile fashion and I accessed the left common femoral artery under local anesthesia using a micropuncture access kit.  A 5 French sheath was easily inserted into the left common femoral artery.  Through the sheath, I then advanced a guidewire and guide catheter, and 3000 units of unfractionated heparin were administered IV.  I could not advance the Omni flush through the device well, and so retrograde angiogram was performed through the 5 French sheath.  No obstruction was noted, and so with some patience, I was able to negotiate the Omni flush catheter through the device after first placing a glide wire through the device, and then placing the Omni flush catheter over the glide wire.  The Omni flush catheter was performed above the level of the endovascular device and an AP angiogram of the abdominal aorta was obtained.  This did demonstrate a small type 2 endoleak.  Several branches appeared to entering the aneurysm sac from the high right sac to the lateral lower left sac.  The lower left sac appeared to be filled late via hypogastric arteries and the high right sac appeared to be filled from a lumbar artery.  

I then pulled the Omni flush catheter into the device itself, and obtained an additional angiogram demonstrating no early endoleak, but again branches radiating from the hypogastric artery on the left up toward the sac itself.  

Several images were obtained.  

I next selectively catheterized the superior mesenteric artery with an Omni SOS catheter.  With the Omni SOS catheter approximately 2 cm into the superior mesenteric artery, there were no significant branches that radiated toward or into the aneurysm sac.  I then pushed the Omni SOS catheter more craniad, and a very high branch appeared to radiate across the abdomen to the left, followed by caudad and followed by toward the aneurysm sac.  I thought that this might be a collateral of the superior mesenteric artery feeding the aneurysm sac.  

I then selectively catheterized the left hypogastric artery.  Two arteries appeared to be [*] ______ off the internal iliac artery toward the aneurysm sac.  With the Omni SOS catheter in the hypogastric artery, I passed a micro-catheter and micro-access wire into the hypogastric artery and I was able to selectively catheterize 1 of these 2 branches.  This branch appeared to enter the aneurysm sac from the left side and was a likely source of endoleak.  With the microcatheter as high into the branch as possible, I was able to pass a micro-coil.  A single 3 mm coil was deployed within the branch successfully.  I then pulled the catheter back, and noted another significant branch of this branch and a second coil was placed.  Further arteriogram showed no significant flow in the aneurysm sac from this branch.  I then pulled the microcatheter back and identified a second branch arising near the origin of the hypogastric artery and radiating craniad toward the aneurysm sac again.  In spite of numerous attempts with different wires and catheters, I was unable to selectively catheterize this branch.  This branch appeared to take a very significant tortuous course off of the hypogastric artery immediately at its origin and also had some narrowing near its origin, which likely is why I was unable to catheterize it.  I eventually desisted with this.  

Next, I used the Omni SOS catheter in conjunction with the micro-access wire to selectively catheterize the high branch of the superior mesenteric artery.  This was successful.  I was able then to negotiate across much of the branch with the microcatheter.  Supra-selective catheterization of this branch with further injection showed that the branch did radiate toward the aneurysm sac, but did not enter the aneurysm sac, and appeared to be perfusing a segment of bowel.  Thus, I did not coil this branch.  Next, I selectively catheterized the right hypogastric artery from the left side and performed additional images on the right side.  This did not demonstrate any significant branches entering the aneurysm sac.  

I decided to accept this result.  All sheaths and guidewires were removed and direct pressure was applied on the patient's common femoral artery site until meticulous hemostasis was achieved.  Of note, I fully heparinized the patient with a total of 5000 units of unfractionated heparin following decision to coil. 

A dry sterile dressing was applied to the puncture site. 

_I come up with the following codes:
75724
75736
75774 x 3
36247
36248
36246-59
36246-59
37204
75894
75898_


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## kgodda1 (May 23, 2011)

I can up with the following codes for this procedure:

37204 
75894
75898
36246 x 3
75726
75736 x 2
75774 x 3

The physician documentation of the final catheter positions could definately have been much clearer in this case.  I was unable to really determine if the catheter was ever really passed into a 3rd order branch or if a flush angiogram was performed from the second order branch to get the findings that are mentioned.  I would err on the side of caution unless you want to query the physician to clarify final catheter positions.  

I would use 75726 for the SMA angio instead of 75724 (Renal angio).


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