antoniamay
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Procedure: 5 vessel cerebral angiogram.
Clinical indication: 65-year-old hypertensive meth abuser found to have intraventricular hemorrhage. Cerebral angiogram was requested to rule out intracranial cerebral aneurysm or periventricular arteriovenous malformation.
Fluoroscopy time: 12.9 minutes.
Fluoroscopy dose: 499 mGy.
Procedure:
Right common carotid and cerebral angiogram
Right internal carotid and cerebral angiogram
Left common carotid and cerebral angiogram
Left internal carotid and cerebral angiogram
Left subclavian and cerebral angiogram
Right common femoral angiogram
The patient was brought to the angiography suite and laid on the stable. Both groins were shaved and prepped in the usual sterile fashion. The EVD was clamped. The patient was covered with a sterile sheet. A hard stop was done identifying the patient, procedure and site.
Access: Using ultrasound guidance, the right common femoral artery was identified. Then using the Seldinger technique, a 4 French 10 cm sheath was inserted into the right common femoral artery and the microwire was removed. A guidewire was inserted into the 4 French sheath which was then exchanged for a 6 French 10 cm short sheath and secured to the right groin. The J-wire was removed.
Right common and cerebral angiogram: Using a Simmonds 2 glide catheter loaded over a 0.035 glidewire, the setup was advanced under fluoroscopy into the aortic arch with the catheter was reformed. It was then introduced into the brachiocephalic and finally into the right common carotid artery. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Right CCA: Smooth and unremarkable.
Right ECA: Smooth and unremarkable lumen. All major branches were identified. No external to internal dural arterial fistulae were visualized in the early arterial phase.
Right ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal. A large posterior communicating arteries seen originating from the cavernous segment, applying the ipsilateral posterior cerebral artery and occipital lobe.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Right internal carotid and cerebral angiogram: Using road-mapping technique, the cervical right ICA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Right ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal. The posterior communicating artery was again observed supplying the right posterior cerebral artery.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, arteriovenous malformations, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Left common and cerebral angiogram: The Simmons 2 glide catheter was advanced under fluoroscopy into the left common carotid artery. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Left CCA: Smooth and unremarkable.
Left ECA: Smooth and unremarkable lumen. All major branches were identified. No external to internal early arterial flow was seen, signifying a dural arterial fistula.
Left ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Minimal atherosclerosis seen in the petrocavernous segment.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush. The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, arteriovenous malformations, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the left CCA.
Left internal carotid and cerebral angiogram: Using road-mapping technique, the cervical left ICA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Left ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, arteriovenous fistula, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Left subclavian angiogram: The Simmons 2 glide catheter was manipulated into the left subclavian. It was difficult to catheterize the vertebral artery because of a sharp angulation just distal to the origin, making it difficult to advance the Glidewire into the artery without risking dissection. Angiographic runs done in the AP, lateral and oblique projections showed:
Vertebral: Slight tortuosity of the V1 and normal V2 and V3 segments. The V4 segment appears normal. The intracranial portion of the vertebral artery is not well visualized. The basilar artery is seen without any major arteriovenous malformations or aneurysms visualized along its course. The posterior cerebral and superior cerebellar arteries are not well visualized. The pontine and anterior or posterior inferior cerebellar arteries are not well visualized.
At this stage, all wires and catheters were removed from the body of the patient.
Closure: Right common femoral angiogram done through the 6F groin sheath showed adequate arteriotomy above its bifurcation into superficial femoral and profunda femoris arteries. A 6F Angioseal device was deployed after withdrawing the sheath over a J wire. Adequate hemostasis was achieved.
Complications: None. A brief neurological exam done at the end of the procedure showed normal vision, speech, right motor and sensory function.
Impression:
5 vessel cerebral angiogram appears unremarkable. No cerebral aneurysm, AVM/AVF, dural venous fistula, vasculitis, tumor blushes or other vascular pathology is seen.
Recommendation:
Abstain from methamphetamine use.
Aggressive treatment of blood pressure keeping below 135/85.
For this the only codes I have so far are as follows and I am sure that is not all it and I need some help understanding modifiers.
36224 - 50
36225
75710
76937
Clinical indication: 65-year-old hypertensive meth abuser found to have intraventricular hemorrhage. Cerebral angiogram was requested to rule out intracranial cerebral aneurysm or periventricular arteriovenous malformation.
Fluoroscopy time: 12.9 minutes.
Fluoroscopy dose: 499 mGy.
Procedure:
Right common carotid and cerebral angiogram
Right internal carotid and cerebral angiogram
Left common carotid and cerebral angiogram
Left internal carotid and cerebral angiogram
Left subclavian and cerebral angiogram
Right common femoral angiogram
The patient was brought to the angiography suite and laid on the stable. Both groins were shaved and prepped in the usual sterile fashion. The EVD was clamped. The patient was covered with a sterile sheet. A hard stop was done identifying the patient, procedure and site.
Access: Using ultrasound guidance, the right common femoral artery was identified. Then using the Seldinger technique, a 4 French 10 cm sheath was inserted into the right common femoral artery and the microwire was removed. A guidewire was inserted into the 4 French sheath which was then exchanged for a 6 French 10 cm short sheath and secured to the right groin. The J-wire was removed.
Right common and cerebral angiogram: Using a Simmonds 2 glide catheter loaded over a 0.035 glidewire, the setup was advanced under fluoroscopy into the aortic arch with the catheter was reformed. It was then introduced into the brachiocephalic and finally into the right common carotid artery. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Right CCA: Smooth and unremarkable.
Right ECA: Smooth and unremarkable lumen. All major branches were identified. No external to internal dural arterial fistulae were visualized in the early arterial phase.
Right ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal. A large posterior communicating arteries seen originating from the cavernous segment, applying the ipsilateral posterior cerebral artery and occipital lobe.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Right internal carotid and cerebral angiogram: Using road-mapping technique, the cervical right ICA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Right ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal. The posterior communicating artery was again observed supplying the right posterior cerebral artery.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, arteriovenous malformations, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Left common and cerebral angiogram: The Simmons 2 glide catheter was advanced under fluoroscopy into the left common carotid artery. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Left CCA: Smooth and unremarkable.
Left ECA: Smooth and unremarkable lumen. All major branches were identified. No external to internal early arterial flow was seen, signifying a dural arterial fistula.
Left ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Minimal atherosclerosis seen in the petrocavernous segment.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush. The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, arteriovenous malformations, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the left CCA.
Left internal carotid and cerebral angiogram: Using road-mapping technique, the cervical left ICA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Left ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, arteriovenous fistula, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Left subclavian angiogram: The Simmons 2 glide catheter was manipulated into the left subclavian. It was difficult to catheterize the vertebral artery because of a sharp angulation just distal to the origin, making it difficult to advance the Glidewire into the artery without risking dissection. Angiographic runs done in the AP, lateral and oblique projections showed:
Vertebral: Slight tortuosity of the V1 and normal V2 and V3 segments. The V4 segment appears normal. The intracranial portion of the vertebral artery is not well visualized. The basilar artery is seen without any major arteriovenous malformations or aneurysms visualized along its course. The posterior cerebral and superior cerebellar arteries are not well visualized. The pontine and anterior or posterior inferior cerebellar arteries are not well visualized.
At this stage, all wires and catheters were removed from the body of the patient.
Closure: Right common femoral angiogram done through the 6F groin sheath showed adequate arteriotomy above its bifurcation into superficial femoral and profunda femoris arteries. A 6F Angioseal device was deployed after withdrawing the sheath over a J wire. Adequate hemostasis was achieved.
Complications: None. A brief neurological exam done at the end of the procedure showed normal vision, speech, right motor and sensory function.
Impression:
5 vessel cerebral angiogram appears unremarkable. No cerebral aneurysm, AVM/AVF, dural venous fistula, vasculitis, tumor blushes or other vascular pathology is seen.
Recommendation:
Abstain from methamphetamine use.
Aggressive treatment of blood pressure keeping below 135/85.
For this the only codes I have so far are as follows and I am sure that is not all it and I need some help understanding modifiers.
36224 - 50
36225
75710
76937