# Help! Mechanical thrombectomy/angioplasty/infusion catheter placement



## margaret fahy (Feb 14, 2014)

02/14/14
Hey Guys,
This one is rather difficult.  So far, I have the following codes:

37187, 37212, 35476, 75978, 36010, 75825...with bundling galore...
Are my main codes okay?...and the Venogram..am I correct to code for IVC Venogram?  Would I also code for vascular access Femoral?...no, right?  Or was it a venogram of femoral vein?

Please help!...Thanks, Margie

CLINICAL HISTORY: History of deep venous thrombosis of the right
common iliac vein and IVC, status post stent placement in outside
hospital several weeks ago. 6 weeks post IVC recanalization the
patient present with grin pain and noted to have iliac and IVC
occlusion at...   

COMPARISON: CT dated January 28, 2014.  

PROCEDURE:
1. Ultrasound guided access of the right common femoral vein.
2. Venogram.
3. Mechanical thrombolysis using 6 French AngioJet catheter.  
4. Venoplasty utilizing 14 mm x 4 cm and 12 mm x 4 cm balloon
catheters.
5. Post venoplasty venogram  
6. Thrombolysis infusion catheter placement.

CONTRAST AND MEDICATIONS:
1. 50 mL of Omnipaque-300.
2. 3000 units of heparin during the procedure with ACT
monitoring.
3. Clindamycin: 10 mg/kg, one dose during the procedure.

PROCEDURE IN DETAIL: The patient was placed supine on the
angiographic table. Scout radiograph of the abdomen demonstrated
a metallic stent extending from infrahepatic IVC into the right
common iliac vein. Limited ultrasound examination of the right
groin was performed. This demonstrated patent and compressible
right common femoral vein. The  right groin region was prepped
and prepped in usual sterile manner. Under ultrasound guidance,
the right common femoral vein was accessed using a 21 gauge
micropuncture needle. An 0.018" Nitrex wire was advanced through
the micropuncture needle into the femoral vein. The needle was
removed and and 4/5 French micropuncture sheath was advanced into
the vein. Advancement of the wire into the IVC was unsuccessful.
The wire was exchanged into 0.035 Newton wire, the sheath was
removed and a 4 French KMP catheter was advanced over the wire
and manipulated until the wire was advanced through the right
common iliac vein stent into the hepatic IVC. Then the catheter
was removed and 6 French vascular sheath was placed into the
right common femoral vein. The contrast was injected and venogram
was obtained which demonstrated total occlusion, secondary to
thrombosis, of the stent extending from the right common iliac
vein into infrahepatic IVC with multiple collaterals. There are 3
metallic stents within the IVC and right common iliac vein, with
stent overlap at the level of the superior right common iliac
vein. However, the superior most metallic stent in IVC is short
without overlap with adjacent inferior stent. The superior struts
of the middle IVC stent are converging and causing severe
narrowing/occlusion of the lumen at that level.

The wire was exchanged into Amplatz wire, over which a 6 French
AngioJet catheter was advanced. Then, 4 mg of TPA was diluted in
50 mL of normal saline and injected within the thrombus from the
right common iliac vein into the hepatic IVC using pulse spray
technique. After 25 minutes, mechanical thrombectomy was
performed using 6 French AngioJet catheter. Post thrombectomy
venogram demonstrated significant resolution of thrombosis with
patency of the right common iliac vein and IVC with 2 areas of
stenosis at the level of the superior struts of the middle IVC
stent. The vascular sheath was upsized into 8 French long
vascular sheath. Angioplasty of the stent was performed using 14
mm x 4 cm balloon catheter in IVC stent and 12 mm x 4 cm balloon
catheter in the right common iliac vein stent. The stenosis at
the level of the superior struts of the middle IVC stent was very
tight. This required using 12 mm 4cm Conquest balloon catheter
initially then 14 mm 4cm Atlas high pressure balloon catheter for
angioplasty. A tight waist was noted at 12mm completely effaced
and then further dilated to 14mm.  

Post angioplasty venogram demonstrated significant improvement of
stenotic areas with interval development of new clots along IVC
and right common iliac vein. At this time, 3000 units of heparin
was given intravenously and mechanical thrombectomy was performed
using 6 French AngioJet catheter. Additional angioplasty of the
IVC stent was performed using 14 mm balloon catheter and right
common iliac vein stent using 12 mm balloon catheter. Contrast
was injected and venogram was obtained which demonstrated
significant resolution of clots in IVC and right common iliac
vein with improvement of the stenotic areas. The superior struts
of the middle IVC stent are diverging.

Then, a 5 F UniFuse infusion catheter with infusion length of 20
cm was advanced over the guide wire. The infusion catheter was
positioned in such a fashion so that the distal end of the
infusion length was at the level of right common iliac vein and
the proximal end of the infusion length at the level of hepatic
IVC.

The sheath and the catheter were then fixed at the skin using
Steri-strips and Tegaderm. Appropriate instructions were given
for tPA and heparin infusion. Team was notified for intravenous
heparinization. Follow up venogram and possible additional
intervention was scheduled for the next day.

FINDINGS:  
A total occlusion, secondary to thrombosis, of the stent within
the right common iliac vein and infrahepatic IVC with multiple
collaterals. Mechanical thrombectomy and angioplasty were
performed.

The patient left the IR suite in stable condition. Dr, was
present throughout the procedure.  

Permanent ultrasound and fluoroscopic images were stored in the
PACS system.


IMPRESSION
1. A total occlusion, secondary to intra stent thrombosis
starting at the  
and infrahepatic IVC with multiple collaterals.
2.  The superior struts of the middle IVC stent are not apposed
and causing severe narrowing/occlusion of the lumen at that
level.
3. Mechanical thrombectomy successfully performed using 6 French
AngioJet catheter with almost complete clot removal.
4. Angioplasty using 14 mm x 4 cm and 12 mm x 4 cm balloon
catheter with significant improvement in the IVC stenosis post.
5. Thrombolysis infusion catheter 5 F 20cm placement as noted
above.


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## dpeoples (Feb 17, 2014)

margaret fahy said:


> 02/14/14
> Hey Guys,
> This one is rather difficult.  So far, I have the following codes:
> 
> ...



Your codes look correct to me. Good job on a long report.

HTH


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## margaret fahy (Feb 17, 2014)

*Mechanical Thrombectomy/Angioplasty*

02/17/14

Dan The Man!
You just made my not too good day so much better.
Thanks so much for the nice comment.
Sincerely,
Margie


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