# Neuro-Endovascular Procedures



## jonyleo20 (Jun 1, 2012)

INTERVENTIONAL NEURORADIOLOGY/ENDOVASCULAR NEUROSURGERY OPERATIVE 
 NOTE 
 PREOPERATIVE DIAGNOSES- 
 VERTEBROBASILAR INSUFFICIENCY
 BILATERAL VERTEBRAL ARTERY OCCLUSIONS
 S/P RIGHT COMMON CAROTID TO RIGHT VERTEBRAL ARTERY VENOUS BYPASS GRAFT

 POSTOPERATIVE DIAGNOSES- 
 SEVERE GRAFT ANASTOMOTIC STENOSIS WITH FLOW RESTRICTION AND THROMBUS
 GRAFT ANASTOMOTIC LEAK 
 IATROGENIC LEFT VERTEBRAL ARTERY DISSECTION/DISSECTING ANEURYSM
 S/P LEFT SUBCLAVIAN SAPTA 

 PROCEDURES\E\OPERATIONS- 
 DIAGNOSTIC FOUR VESSEL-VASCULAR FAMILY CATHETER CEREBRAL/CERVICAL DSA 
 STENT-ASSISTED ANEURYSM OCCLUSION OF LEFT VERTEBRAL ARTERY DISSECTING 
 ANEURYSM
 MECHANICAL THROMBOLYSIS OF GRAFT/DISTAL ANASTOMOSIS
 STENT-ASSISTED PERCUTANEOUS ANGIOPLASTY OF RIGHT COMMON CAROTID 
 BYPASS GRAFT
 BALLOON TAMPONADE OF ANASTOMOTIC LEAK

 NEURO ENDOVASCULAR SURGEON- JOHN C. CHALOUPKA, MD, FAHA, FACA 

 ANESTHESIA- GETA^ SEE ANESTHESIA NOTES FOR DETAILS

 COMBINED ESTIMATED BLOOD LOSS- 500 ML. 

 COMPLICATIONS- GRAFT ANASTOMOTIC LEAKAGE AFTER PTA REQUIRING BALLOON 
 TAMPONADE AND SURGICAL REVISION

 INDICATIONS- SEVERELY SYMPTOMATIC VERTEBROBASILAR INSUFFICIENCY 
 SECONDARY TO BILATERAL VERTEBRAL ARTERY OCCLUSIONS^ S/P LEFT 
 SUBCLAVIAN ARTERY SAPTA^ S/P RECENT RCCA TO RVA BYPASS^ EVALUATE 
 PATENCY OF GRAFT. 

 MATERIALS EMPLOYED- 
 18G SINGLE WALL PUNCTURE NEEDLE 
 6FR 11 CM SHEATH, 
 BENTSON 0.038" GUIDE WIRE, 
 0.035" TERUMO GUIDE WIRE, 
 5FR ANGLED GLIDE DIAGNOSTIC CATHETER, 
 6FR 90-CM ENVOY MPD,
 4.5-MM X 37-MM ENTERPRISE STENT, AND
 4.5 X 15 MILLIMETER WINGSPAN STENT,
 3.5 MM X 9 MM GATEWAY PTA BALLOON MICROCATHETER
 4 MM X 9 MM GATEWAY PTA MICHAEL BALLOON CATHETER
 014 300-CM PT GRAPHIX EXCHANGE CORONARY WIRE
 0.027" PROWLER SELECT PLUS MICROCATHETER
 VESSELS INJECTED- 
 RIGHT COMMON CAROTID ARTERY, 
 RIGHT SUBCLAVIAN ARTERY, 
 RIGHT VERTEBRAL ARTERY, 
 RIGHT DEEP CERVICAL ARTERY, 
 THE PROCEDURE, ITS RISKS (INCLUDING STROKE, DEATH, BLEEDING, COMA, 
 DAMAGE TO BLOOD VESSELS, INFECTION, AND ADVERSE REACTION TO 
 MEDICATIONS), BENEFITS, AND ALTERNATIVES WERE DISCUSSED WITH THE 
 PATIENT AND HIS FAMILY (WIFE AND SONS). ALL QUESTIONS WERE ANSWERED 
 AND INFORMED CONSENT WAS OBTAINED. THE PATIENT WAS BROUGHT INTO THE 
 NEURO-INTERVENTIONAL SUITE AND PLACED ON THE FLUORO/DSA TABLE IN A 
 SUPINE POSITION. A PROCEDURAL TIMEOUT WAS TAKEN TO VERIFY THE CORRECT 
 PATIENT AND INTERVENTION. THE RIGHT GROIN WAS PREPPED AND DRAPED IN 
 THE USUAL STERILE FASHION. THE RIGHT COMMON FEMORAL ARTERY WAS 
 ACCESSED VIA A MODIFICATION OF THE SELDINGER TECHNIQUE USING SINGLE 
 PUNCTURE TECHNIQUE WITH AN #18G SINGLE-WALL NEEDLE. INITIALLY A #5 
 FRENCH 23 CM TERUMO SHEATH WAS COAXIALLY PLACED OVER A GUIDEWIRE 
 THROUGH THE RIGHT CFA ARTERIOTOMY AND CONNECTED TO A PRESSURIZED 
 CONTINUOUS HEPARINIZED NORMAL INFUSION 
 THE 5-FRENCH ANGLED GLIDE DIAGNOSTIC CATHETER WAS SERIALLY ADVANCED 
 OVER A 0.035" TERUMO GLIDEWIRE INTO THE ASCENDING AORTA, AND THEN 
 MANIPULATED SERIALLY INTO THE GREAT VESSELS UNDER UNSUBTRACTED 
 FLUOROSCOPIC GUIDANCE FOR SELECTIVE CATHETERIZATION DSA AS FOLLOWS- 
 THE RIGHT COMMON CAROTID ARTERY WAS SELECTIVELY CATHETERIZED. BIPLANE 
 CERVICAL CAROTID ANGIOGRAPHY WAS PERFORMED. MULTIPLANAR CEREBRAL 
 CAROTID ANGIOGRAPHY WAS THEN PERFORMED. 
 THE RIGHT SUBCLAVIAN ARTERY WAS SELECTIVELY CATHETERIZED. BIPLANE 
 UPPER THORACIC AND CERVICAL DSA WAS PERFORMED. 
 THE RIGHT VERTEBRAL ARTERY WAS SELECTIVELY CATHETERIZED. BIPLANAR 
 CEREBRAL ANGIOGRAPHY WAS PERFORMED. 
 RIGHT DEEP CERVICAL ARTERY WAS SELECTIVELY CATHETERIZED. BIPLANE 
 UPPER THORACIC AND CERVICAL DSA WAS PERFORMED. 

 FINDINGS- 
 RIGHT COMMON CAROTID ARTERY CERVICAL ANGIOGRAM- 
 POSTOPERATIVE CHANGES SEEN WITHIN THE MID CERVICAL PORTION OF THE 
 RIGHT COMMON CAROTID ARTERY CONSISTING OF AN ECCENTRIC CURVILINEAR 
 ENDOLUMINAL FILLING DEFECT ALONG THE MEDIAL WALL OF THE RIGHT COMMON 
 CAROTID ARTERY WITH A SMALL AREA OF CENTRAL FOCAL OUTPOUCHING 
 PROJECTING MEDIALLY. THIS DEFECT IS SEEN IN THE VICINITY OF SMALL 
 SURGICAL CLIPS AND IS LIKELY THE SITE OF ANASTOMOSIS BETWEEN RIGHT 
 COMMON CAROTID ARTERY AND RIGHT VERTEBRAL ARTERY. THERE IS NO FLOW 
 SEEN WITHIN THE ORIGINAL GRAFT.
 A NEW BYPASS GRAFT IS SEEN JUST DISTAL TO THE ORIGINAL SITE 
 CONSISTING OF AN END TO SIDE ANASTOMOSIS OF INTERPOSED SAPHENOUS VEIN 
 WHICH THEN TRAVELS INFERIORLY AND POSTERIORLY TO AN END TO END 
 ANASTOMOSIS WITH THE MOBILIZED LOWER CERVICAL RIGHT VERTEBRAL ARTERY. 
  THERE IS EVIDENCE OF THROMBUS FORMATION JUST PROXIMAL TO THE DISTAL 
 ANASTOMOTIC SITE WITH THE VERTEBRAL ARTERY.  FURTHERMORE, AT THE 
 DISTAL ANASTOMOTIC SITE WITH THE VERTEBRAL ARTERY, THERE IS A SEVERE 
 ANASTOMOTIC STENOSIS MEASURING OVER 95%.  THERE IS ASSOCIATED FLOW 
 RESTRICTION.  THERE IS AN IATROGENIC DISSECTION OF THE PROXIMAL 
 CERVICAL LEFT VERTEBRAL ARTERY RESULTING IN A DISSECTING ANEURYSM 
 WITH FLOW WITHIN THE FALSE LUMEN.  A PROMINENT FLAP IS SEEN AS WELL.  
 ADDITIONALLY, THERE IS INTERMITTENT EXTRAVASATION SEEN WITHIN THE 
 DISTAL VENOUS GRAFT, WHICH APPEARS TO POTENTIALLY BE ARISING FROM A 
 SMALL TRIBUTARY BRANCH ATTACHED TO THE VEIN.  THERE IS A MILD AMOUNT 
 OF EXTRAVASATION NOTED INTERMITTENTLY.  
 THE RIGHT CAROTID ARTERY TREE SHOWS MILD-MODERATE ATHEROSCLEROTIC 
 DISEASE AFFECTING THE COMMON CAROTID BIFURCATION AND INTERNAL CAROTID 
 ARTERY BULB. THERE IS EFFACEMENT OF THE RIGHT INTERNAL CAROTID ARTERY 
 BULB. THERE IS A PROMINENT SIGMOIDAL CERVICAL LOOP WITH A HORIZONTAL 
 KINK-LIKE STENOSIS RESULTING IN APPROXIMATELY 50% NARROWING. 
 DOLICHOECTASIA. THE VISUALIZED PORTIONS OF THE EXTERNAL CAROTID 
 ARTERY AND ITS BRANCHES ARE OF NORMAL COURSE AND CALIBER. PATHOLOGIC 
 COLLATERALS WITHIN THE RIGHT SUBOCCIPITAL CARREFOUR VIA RIGHT 
 OCCIPITAL ARTERY ARE AGAIN NOTED TO BE RECONSTITUTING THE DISTAL 
 CERVICAL PORTION OF THE RIGHT VERTEBRAL ARTERY. 
 THE INTRACRANIAL PORTIONS OF THE RIGHT INTERNAL ARTERY SHOW NORMAL 
 CALIBER AND COURSE. THERE IS A NARROW NECK, APPROXIMATELY 4-MM 
 SPHERICAL ANEURYSM ARISING FROM THE ANTICIPATED ORIGIN OF THE RIGHT 
 POSTERIOR COMMUNICATING ARTERY. THERE IS NORMAL CAROTID TERMINAL 
 BIFURCATION INTO RIGHT A1 ACA AND RIGHT M1 MCA BRANCHES. THE RIGHT M1 
 SEGMENT IS ALSO NORMAL IN CALIBER AND COURSE. DISTAL MCA AND ACA 
 TERRITORIES SHOW NORMAL DISTRIBUTION AND COURSE. THERE IS NORMAL 
 TRANSIT TIME. THERE IS SPONTANEOUS CROSS FILLING INTO THE LEFT ACA 
 TERRITORY FROM A PATENT ANTERIOR COMMUNICATING ARTERY. THERE IS NO 
 EVIDENCE OF ADDITIONAL ANEURYSMS, ARTERIOVENOUS AUTOMATION, OR 
 ARTERIOVENOUS SHUNTING. 
 RIGHT SUBCLAVIAN ARTERY ANGIOGRAM- THE RIGHT SUBCLAVIAN ARTERY SHOWS 
 MILD DOLICHOECTASIA AND SCATTERED ATHEROSCLEROTIC PLAQUE, 
 PARTICULARLY IN THE PROXIMAL SEGMENT IN WHICH THERE IS AN ECCENTRIC 
 CALCIFICATION. HOWEVER, NO HEMODYNAMICALLY SIGNIFICANT STENOSES ARE 
 IDENTIFIED. THERE IS COMPLETE 100% OCCLUSION AT THE ORIGIN OF THE 
 RIGHT VERTEBRAL ARTERY. THERE IS NOW MINIMAL COLLATERAL FILLING OF 
 THE CERVICAL PORTION OF THE RIGHT VERTEBRAL ARTERY FROM MUSCULAR 
 COLLATERALS ARISING FROM  THE DEEP CERVICAL ARTERY. THE MAJOR 
 BRANCHES ARISING FROM THE SUBCLAVIAN ARTERY ARE PROMINENT, OWING TO 
 COLLATERAL RECRUITMENT. 
 RIGHT DEEP CERVICAL ARTERY DSA- IS NOTABLE FOR GIVING RISE TO DISTAL 
 AND MID CERVICAL MUSCULAR BRANCHES THAT HAVE BEEN THE PREDOMINANT 
 COLLATERAL SUPPLY FOR RECONSTITUTION THE CERVICAL RIGHT VERTEBRAL 
 ARTERY. HOWEVER THESE COLLATERALS ARE LESS PROMINENT THAN PREVIOUSLY 
 NOTED OWING TO THE NEWLY CONSTRUCTED RCCA TO RVA BYPASS GRAFT. 
 (MULTIPLANAR VIEWS)- SELECTION OF THE RIGHT VERTEBRAL ARTERY VIA THE 
 BYPASS GRAFT IS NOTABLE FOR A 2.5 CENTIMETER LENGTH OF DISSECTING 
 ANEURYSM WITH FALSE LUMEN NOTED ALONG THE MEDIAL ASPECT OF THE 
 VESSEL.  THE RIGHT VERTEBRAL ARTERY IS DOMINANT WITH A UNIFORMLY 
 LARGE DIAMETER MEASURING AT LEAST 5 MM.  THERE IS MILD 
 ATHEROSCLEROTIC DISEASE SEEN WITHIN THE LOWER AND MID CERVICAL 
 SEGMENTS WITHOUT HEMODYNAMICALLY SIGNIFICANT STENOSIS.  VERTEBRAL 
 ARTERY JOINS THE VERTEBRAL BASILAR JUNCTION WITH NORMAL VISUALIZATION 
 OF THE VERTEBRAL BASILAR CIRCULATION AS DESCRIBED IN PREVIOUS 
 STUDIES.  NO THROMBOEMBOLIC PHENOMENA ARE NOTED.  
 ENDOVASCULAR OPERATIONS-
 FOR THE ENDOVASCULAR SURGICAL PORTIONS OF THE PROCEDURE, THE 
 INDWELLING RIGHT COMMON FEMORAL ARTERY SHEATH WAS EXCHANGED FOR A 
 6-FRENCH 23 CM TERUMO SHEATH POSITIONED IN THE LOWER ABDOMINAL AORTA. 
  THROUGH THE SHEATH A NUMBER 6-FRENCH 90-CM MPD GUIDING CATHETER WAS 
 POSITIONED WITHIN THE RIGHT COMMON CORONARY AND CAREFULLY MANIPULATED 
 AT THE ORIGIN OF THE PROXIMAL ANASTOMOSIS BETWEEN RIGHT COMMON 
 CAROTID ARTERY AND RIGHT VERTEBRAL ARTERY.  THROUGH THE GUIDING 
 CATHETER MULTIPLE INTERVENTIONS WERE PERFORMED AS FOLLOWS-
 NEURO-ENDOVASCULAR OPERATION #1- MECHANICAL THROMBOLYSIS OF 
 GRAFT/DISTAL ANASTOMOSIS
 A PROWLER PLUS SELECT MICROCATHETER AND SYNCHRO-2 014 MICROGUIDEWIRE 
 COMBINATION WAS MANIPULATED INTO THE BYPASS GRAFT AND NAVIGATED TO 
 THE PROXIMAL EXTENT OF THE GRAFT THROMBUS.  MECHANICAL THROMBOLYSIS 
 WAS THEN PERFORMED USING BOTH THE MICROGUIDEWIRE AND MICROCATHETER.  
 DURING THIS TIME CONTINUOUS SUCTION ASPIRATION OF THE PROXIMAL GRAFT 
 WAS PERFORMED THROUGH THE GUIDING CATHETER POSITIONED WITHIN THE 
 PROXIMAL ANASTOMOSIS.  CONTROL DSA FROM COMMON CAROTID INJECTION 
 SHOWED COMPLETE REMOVAL OF THE THROMBUS.  THERE REMAINS A SEVERE 
 RESIDUAL DISTAL ANASTOMOTIC STENOSIS MEASURING OVER 95%.
 NEURO-ENDOVASCULAR OPERATION #2- STENT-ASSISTED ANEURYSM OCCLUSION
 THE PROWLER PLUS MICROGUIDEWIRE COMBINATION WAS THEN NAVIGATED ACROSS 
 THE SEVERE STENOSIS INTO THE PROXIMAL CERVICAL RIGHT VERTEBRAL 
 ARTERY.  SUPERSELECTED TEST INJECTION THROUGH THE MICROCATHETER AGAIN 
 NOTED THE PSEUDOANEURYSM FORMATION DESCRIBED ABOVE.  UNDER CONTINUOUS 
 FLUOROSCOPIC GUIDANCE AND DIGITAL ROADMAP FLUOROSCOPY, THE 
 MICROCATHETER WAS CAREFULLY NAVIGATED THROUGH THE TRUE LUMEN AND PAST 
 THE AREA OF THE  DISSECTING ANEURYSM INTO AND ANGIOGRAPHICALLY NORMAL 
 SEGMENT OF THE CERVICAL RIGHT VERTEBRAL ARTERY.  MEASUREMENTS WERE 
 MADE TO DETERMINE THE OPTIMAL LENGTH OF STENT NECESSARY TO TREAT THE 
 PSEUDOANEURYSM.  A 4.5 MM X 37 MM ENTERPRISE STENT WAS THEN LOADED 
 INTO THE MICROCATHETER AND PUSHED INTO POSITION ACROSS THE DISSECTING 
 ANEURYSM.  CAREFUL AND SLOW UNSHEATHING UNDER DIGITAL ROADMAP WAS 
 THEN PERFORMED PERMITTING DEPLOYMENT OF THE STENT ACROSS THE ENTIRE 
 EXTENT OF THE DISSECTING ANEURYSM.  CONTROL ANGIOGRAPHY IMMEDIATELY 
 UPON DEPLOYMENT OF THE STENT SHOWED NEARLY COMPLETE OCCLUSION OF THE 
 FALSE CHANNEL WITH SUBSTANTIALLY REDUCED FILLING OF THE 
 PSEUDOANEURYSM. INTERMITTENT EXTRAVASATION ARISING FROM THE SAME 
 POINT WITHIN THE SEPTUM IS GRAFT WAS NOTED.
 NEURO-ENDOVASCULAR OPERATION #3- STENT-ASSISTED PERCUTANEOUS 
 ANGIOPLASTY OF RIGHT COMMON CAROTID BYPASS GRAFT
 THE DISTAL ANASTOMOTIC STENOSIS WAS RECROSSED WITH THE PROWLER PLUS 
 SELECT MICROCATHETER AND SYNCHRO SOFT MICROGUIDEWIRE IN WHICH DISTAL 
 PURCHASE WAS OBTAINED WITHIN THE MID CERVICAL VERTEBRAL ARTERY PAST 
 THE STENTED DISSECTING ANEURYSM SEGMENT.  IT 300-CM PT GRAPHIX 
 EXCHANGE WIRE WAS THEN PLACED INTO POSITION, ALLOWING REMOVAL OF THE 
 MICROCATHETER.  OVER THE EXCHANGE WIRE, A 4.5 MILLIMETER X 15-MM 
 WINGSPAN SELF EXPANDING STENT DELIVERY SYSTEM WAS NAVIGATED ACROSS 
 THE STENOSIS IN WHICH THE STENT DISTAL AND PROXIMAL MARKER BANDS WERE 
 POSITIONED EQUI-DISTANCE FROM THE STENOSIS.  UNDER CONTINUOUS 
 FLUOROSCOPIC GUIDANCE AND DIGITAL ROADMAP FLUOROSCOPY, THE STENT WAS 
 SLOWLY DEPLOYED USING UNSHEATHING TECHNIQUE.  THE STENT DEPLOYED 
 FULLY ACROSS THE TARGETED STENOSIS WITH GOOD APPROXIMATION SEEN 
 DISTALLY AND PROXIMALLY FROM GRAFT TO PROXIMAL CERVICAL VERTEBRAL 
 ARTERY.  THERE WAS IMMEDIATELY IMPROVED RESTORATION OF LUMINAL 
 DIAMETER AT THE ANASTOMOSIS SECONDARY TO POSITIVE REMODELING FORCE OF 
 THE SELF-EXPANDING STENT.  HOWEVER, CONTROL DSA AFTER DEPLOYMENT 
 SHOWED SIGNIFICANT RESIDUAL ANASTOMOTIC STENOSIS WHICH REQUIRED POST 
 DILATATION.  CONSEQUENTLY, A 4-MM X 9-MM GATEWAY PTA BALLOON CATHETER 
 WAS NAVIGATED THROUGH THE WINGSPAN STENT INTO THE ANASTOMOTIC 
 STENOSIS.  PROPER POSITIONING WAS CONFIRMED ON DIGITAL SUBTRACTION 
 ANGIOGRAPHY AND ROADMAP FLUOROSCOPY.  UNDER CONTINUOUS FLUOROSCOPIC 
 GUIDANCE, THE BALLOON WAS SLOWLY INFLATED TO SUBNORMAL PRESSURES IN 
 WHICH ABATEMENT OF WASTING WAS NOTED.  THREE CYCLES OF BALLOON 
 INFLATION/DEFLATION WERE PERFORMED.  FINAL CONTROL DSA AFTER PTA 
 SHOWED SIGNIFICANTLY IMPROVED RESTORATION OF LUMINAL DIMENSION OF THE 
 ANASTOMOSIS.  THERE WAS STILL RESIDUAL STENOSIS MEASURING 
 APPROXIMATELY 25 TO 30%.  THERE WAS ALSO CONTINUED EVIDENCE OF 
 EXTRAVASATION SEEN AT THE ORIGINAL PREINTERVENTION SITE OF THE GRAFT, 
 AS WELL AS AT THE AREA OF RECENTLY DILATED ANASTOMOSIS. THE DEGREE OF 
 EXTRAVASATION HAS INCREASED SINCE THE BEGINNING OF THE CASE.  THIS 
 PROMPTED ADDITIONAL INTERVENTION IS DESCRIBED BELOW.
 NEURO-ENDOVASCULAR OPERATION #4- BALLOON TAMPONADE OF ANASTOMOTIC LEAK
 INITIALLY, THE 4-MM X 9-MM GATEWAY PTA BALLOON MICROCATHETER WAS 
 REPOSITIONED ACROSS THE AREAS OF VISUALIZED EXTRAVASATION AND THEN 
 INFLATED TO SUBNORMAL PRESSURES UNTIL FLOW REST WAS ACHIEVED.  
 BALLOON TAMPONADE WAS PERFORMED INTERMITTENTLY OVER PERIODS OF 2-5 
 MINUTES AT A TIME.  SEVERAL INTERVAL ANGIOGRAMS WERE PERFORMED AFTER 
 DEFLATION OF THE BALLOON IN WHICH THERE WAS TRANSIENT REDUCTION OF 
 EXTRAVASATION.  HOWEVER, DELAYED CONTROL RUNS SHOWED CONTINUED 
 BLEEDING WHICH WAS ESSENTIALLY CHANGED FROM THE RATE OF EXTRAVASATION 
 SEEN BEFORE IMPLEMENTING BALLOON TAMPONADE.  CONSEQUENTLY, A LARGER 
 PTA BALLOON WAS SELECTED CONSISTING OF A 4.5-MM X 9-MM GATEWAY PTA 
 BALLOON MICROCATHETER.  AGAIN, THE MICROCATHETER WAS REPOSITIONED 
 ACROSS THE AREAS ARE VISUALIZED EXTRAVASATION AND THEN CYCLICALLY 
 INFLATED TO SUBNORMAL PRESSURES UNTIL FLOW ARREST WAS ACHIEVED.  
 OCCLUSION TIMES FROM 5 TO 10 MINUTES WERE UTILIZED CYCLICALLY.  
 UNFORTUNATELY, AGAIN ALTHOUGH INITIAL SUBSTANTIAL REDUCTION OF 
 EXTRAVASATION WAS SEEN UPON IMMEDIATE DEFLATION OF THE BALLOON, 
 REPEAT CONTROL DSA SHOWED RETURNED BLEEDING TO PREINTERVENTION 
 LEVELS.  MULTIPLE INFLATION CYCLES WERE MADE OVER A PERIOD OF 
 APPROXIMATELY 40 MINUTES.  AT THIS JUNCTURE IN COLLABORATION WITH 
 DR.SAVINA  AND DR. KANTROWITZ KANTROWITZ, IT WAS ELECTED TO REEXPLORE 
 THE ANASTOMOSIS TO IDENTIFY THE SOURCE OF BLEEDING AND CORRECT IT 
 WITH AN OPEN SURGICAL PROCEDURE.
 ENDOVASCULAR OPERATION #5- RIGHT COMMON ILIAC ANGIOGRAPHY & 
 PERCUTANEOUS ARTERIOTOMY CLOSURE 
 COMPLICATIONS- NONE. 
 INDICATIONS- PROLONGED ARTERIAL SHEATH PLACEMENT WITH NEED FOR 
 INTERMITTENT ANTICOAGULATION.
 MATERIALS EMPLOYED- 6FR, 11 CM SHEATH, BENTSON 0.038" GUIDE WIRE, 
 ANGIO-SEAL 6-FRENCH KIT 
 VESSELS INJECTED- AORTO-ILIAC BIFURCATION\S\ LEFT COMMON ILIAC 
 ARTERY PROCEDURE- CONTROL DSA THROUGH AORTO-ILIAC AND RIGHT COMMON 
 ILIAC ARTERY INJECTION WERE PERFORMED. 
 FINDINGS- MILD BILATERAL ILIAC BIFURCATION ATHEROSCLEROTIC DISEASE 
 WITHOUT STENOSIS OR OCCLUSION. NORMAL TRANSIT TIME. NORMAL BILATERAL 
 COMMON ILIAC ARTERIES WITHOUT EVIDENCE OF STENOSIS. RIGHT COMMON 
 ILIAC ARTERY INJECTION SHOWS NORMAL CALIBER AND COURSE OF THE RIGHT 
 COMMON ILIAC ARTERY THE RIGHT COMMON ILIAC BIFURCATION, RIGHT 
 INTERNAL AND EXTERNAL ILIAC ARTERIES. THERE IS NO EVIDENCE OF 
 INTRALUMINAL THROMBUS OR DISTRACTION. THERE IS NORMAL RAPID RUNOFF. 
 NO INTIMAL INJURY IS SEEN IN THE LEFT COMMON FEMORAL ARTERIOTOMY. THE 
 ARTERIOTOMY IS BELOW THE INGUINAL LIGAMENT AND ABOVE THE RIGHT COMMON 
 FEMORAL ARTERY BIFURCATION. THE ARTERIAL ACCESS SHEATH WAS THEN 
 EXCHANGED OVER A WIRE FOR THE ACCESS SHEATH USED WITH THE 6-FRENCH 
 ANGIO-SEAL KIT. PROPER POSITIONING OF THE SHEATH WAS CONFIRMED 
 THROUGH PULSATILE BLOOD FLOW IN WHICH WIRE AND DILATOR WERE REMOVED 
 AND EXCHANGED FOR THE ANGIO-SEAL PLUGS. THE PLUGS WERE PLACED IN 
 STANDARD FASHION IN WHICH GOOD HEMOSTASIS WAS ACHIEVED. RIGHT COMMON 
 FEMORAL ARTERY WAS STILL EASILY PALPATED. FULL HEMOSTASIS WAS 
 ACHIEVED. 
 FINAL IMPRESSIONS/SUMMARY- 
 1. PATENT 2ND BYPASS GRAFT JUST DISTAL TO THE ORIGINAL SITE 
 CONSISTING OF END TO SIDE ANASTOMOSIS OF INTERPOSED SAPHENOUS VEIN 
 WHICH THEN TRAVELS INFERIORLY AND POSTERIORLY TO AN END TO END 
 ANASTOMOSIS WITH THE MOBILIZED LOWER CERVICAL RIGHT VERTEBRAL ARTERY. 
  THROMBUS FORMATION JUST PROXIMAL TO THE DISTAL ANASTOMOTIC SITE WITH 
 THE VERTEBRAL ARTERY.  DISTAL ANASTOMOTIC SITE HAS A SEVERE 
 ANASTOMOTIC STENOSIS MEASURING OVER 95%. INTERMITTENT EXTRAVASATION 
 ARISING FROM DISTAL VENOUS GRAFT, WHICH APPEARS TO ARISE FROM A SMALL 
 TRIBUTARY BRANCH ATTACHED TO THE VEIN.  
 2. OCCLUDED 1ST RCCA TO R VA VENOUS BYPASS GRAFT RIGHT 
 3. IATROGENIC DISSECTION/DISSECTING ANEURYSM OF PROXIMAL CERVICAL 
 RIGHT VERTEBRAL ARTERY
 4. TECHNICALLY SUCCESSFUL STENT-ASSISTED ANEURYSM OCCLUSION OF 
 DISSECTING ANEURYSM OF PROXIMAL CERVICAL RIGHT VERTEBRAL ARTERY
 5. TECHNICALLY SUCCESSFUL MECHANICAL THROMBOLYSIS OF GRAFT/DISTAL 
 ANASTOMOSIS
 6. TECHNICALLY SUCCESSFUL STENT-ASSISTED PERCUTANEOUS ANGIOPLASTY OF 
 RIGHT COMMON CAROTID BYPASS GRAFT
 7. TECHNICALLY UNSUCCESSFUL BALLOON TAMPONADE OF ANASTOMOTIC LEAKS
 8. TECHNICALLY SUCCESSFUL PERCUTANEOUS ARTERIOTOMY CLOSURE WITH 6 FR 
 ANGIOSEAL DEVICE 

HELP PLS !!!!!!!!!!!!!!!!!!!!!!1


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## dpeoples (Jun 1, 2012)

That will give you a big headache.

without really dissecting this, I am thinking
0075t for the Vert stent
0076T for the CC stent.
These codes include all cath placements and diagnostic images.

HTH


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## donnajrichmond (Jun 1, 2012)

Well the first thing I would do is talk to whomever is in charge of your reporting system and make them change from all CAPS to sentence case - this was really hard to read!

There was also mechanical thrombectomy in there, so 36174.  And I'm not sure about the balloon tamponade - that took a long time and was separate from the stenting - possibly 37799.
Danny, Jim - what do y'all think?


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