carelitz
Guest
This is completely new to me and I would appreciate any help or insights. I cannot find much info coding what i think is a TEVAR. Thanks so much in advance!
The codes i came up with are:
36200 50 (cath placements)
37252 (IVUS)
33881 62 (endovascular repair...no subclavian coverage)
75957 26 (imaging...not involving coverage of subclavian)
34812 (large bore femoral access)
CO-SURGEON PERFORMING PROCEDURE:
PROCEDURES PERFORMED:
1. Large bore femoral access.
2. Nonselective catheter placement to the ascending aorta.
3. Endovascular repair of descending thoracic aorta not involved in
coverage of the left subclavian.
4. Supervision interpretation of the aortogram.
5. Aortic intravascular ultrasound.
INDICATIONS FOR PROCEDURE: This is a gentleman with a known
history of coronary artery disease, carotid stent, hypertension,
dyslipidemia, who had bypass surgery successful in August 2020. He
continued having chest pain and was found to have penetrating aortic ulcer
of his descending aorta 2 cm distal to the left subclavian artery, the
respective CT scan was fully assessed, and the patient was suitable for
endovascular repair. Pros and cons of procedure were discussed in many
details, consent was obtained.
DESCRIPTION OF PROCEDURE: After obtaining informed written the patient's
consent, he was brought to the hybrid OR room. Appropriate timeout was
called. General anesthesia was provided by the Department of Anesthesia,
Dr., please see separate report, patient was intubated and
ventilated, he had transesophageal echocardiogram probe placed in his
esophagus, and TEE was performed by Dr. throughout the procedure,
please see separate report.
Once the patient was sterilely prepped and adequately sedated, the
procedure commenced.
The main access was obtained to the right common femoral artery with
micropuncture kit, modified Seldinger technique under ultrasound direction
and initially 8-French sheath was placed. Prior to placing an 8-French
sheath, we had 3 ProGlide Perclose catheters delivered at 10 o'clock, 12
o'clock and 2 o'clock for preclosure.
Second arterial access was obtained to the left common femoral artery with
micropuncture kit, modified Seldinger technique, and direct ultrasound
visualization and 6-French 45 cm Destination sheath was positioned through
the very tortuous iliac artery to the descending aorta over the 180 cm
SupraCore wire.
Then, with the SupraCore wire from the right femoral approach, we
positioned the JR4 catheter to the ascending aorta and exchanged the wire
to 300 cm double curve Lunderquist wire with a loop of the wire in the
aortic root. The JR4 catheter was removed. The 8-French sheath from the
right femoral was removed. Pre-dilatation with 12, 16, 20 and 22 dilator
was performed and then 22-French Gore sheath, 30 cm sheath, was advanced
under fluoroscopy control and positioned to the distal aorta over the
Lunderquist wire.
Then, the 5-French pigtail catheter was advanced from the left femoral
approach and positioned to the distal ascending aorta and the aortic arch
and aortogram obtained at 40-degree LAO projection with power injection.
The vessels were clearly identified.
Then, 0.035 Phillips intravascular ultrasound catheter was advanced over
the Lunderquist wire to the ascending aorta and pullback was performed and
intravascular ultrasound obtained.
INTRAVASCULAR ULTRASOUND FINDINGS: This intravascular ultrasound showed
that the wire was in the true lumen of the aorta. The aortic size
immediately distal to the left subclavian was x 28 mm with area of
661 mm2. The aortic measurements in the mid portion of the aortic
ulceration were 27 x 26 mm ulceration across its diameter was 16 mm.
Once all the orientation of the branches including left subclavian artery,
innominate artery, and position of the ulcer were confirmed, we advanced
the Gore 34 x 10 cm cTAG stent graft initially advanced beyond the
innominate artery, then slowly pulled it back and positioned immediately
distal to the origin of the left subclavian artery. It was 50 percent
deployed and then another aortogram was obtained, which confirmed
excellent position of the device and device was fully deployed. Prior to
full deployment, the pigtail was pulled in the abdominal aorta, after
deployment, it was advanced through the new stent graft again to the
aortic arch and confirmatory angiogram obtained, which showed excellent
stent expansion, position and apposition without any evidence of endoleak
and beyond the stent graft with excellent flow in the aorta.
The delivery system was removed. We then removed the 22-French sheath
from the right femoral artery and tightened the sutures. For the
procedure, the patient was heparinized with ACT more than 250. Heparin
was provided by cardiac anesthesia and it was partially reversed at the
end of the procedure. The Perclose sutures were tightened. There was no
residual bleeding from the right groin.
The 6-French 45 cm sheath was removed from the left femoral access and
6-French Angio-Seal closure device successfully deployed without any
residual bleeding.
Overall, estimated blood loss was about 100 mL
There were no immediate complications.
CONCLUSIONS:
1. Penetrating aortic ulcer, symptomatic.
2. Successful endovascular repair of the descending thoracic aorta not
involved in coverage of the left subclavian with 34 x 10 cm Gore
cTAG stent graft.
3. Large bore access to the right femoral artery with successful
preclosure.
4. Nonselective aortic catheter placement and radiologic supervision
and interpretation.
5. Intravascular ultrasound of the aortic arch and descending aorta.
6. The patient to continue his current therapy including aspirin.
The codes i came up with are:
36200 50 (cath placements)
37252 (IVUS)
33881 62 (endovascular repair...no subclavian coverage)
75957 26 (imaging...not involving coverage of subclavian)
34812 (large bore femoral access)
CO-SURGEON PERFORMING PROCEDURE:
PROCEDURES PERFORMED:
1. Large bore femoral access.
2. Nonselective catheter placement to the ascending aorta.
3. Endovascular repair of descending thoracic aorta not involved in
coverage of the left subclavian.
4. Supervision interpretation of the aortogram.
5. Aortic intravascular ultrasound.
INDICATIONS FOR PROCEDURE: This is a gentleman with a known
history of coronary artery disease, carotid stent, hypertension,
dyslipidemia, who had bypass surgery successful in August 2020. He
continued having chest pain and was found to have penetrating aortic ulcer
of his descending aorta 2 cm distal to the left subclavian artery, the
respective CT scan was fully assessed, and the patient was suitable for
endovascular repair. Pros and cons of procedure were discussed in many
details, consent was obtained.
DESCRIPTION OF PROCEDURE: After obtaining informed written the patient's
consent, he was brought to the hybrid OR room. Appropriate timeout was
called. General anesthesia was provided by the Department of Anesthesia,
Dr., please see separate report, patient was intubated and
ventilated, he had transesophageal echocardiogram probe placed in his
esophagus, and TEE was performed by Dr. throughout the procedure,
please see separate report.
Once the patient was sterilely prepped and adequately sedated, the
procedure commenced.
The main access was obtained to the right common femoral artery with
micropuncture kit, modified Seldinger technique under ultrasound direction
and initially 8-French sheath was placed. Prior to placing an 8-French
sheath, we had 3 ProGlide Perclose catheters delivered at 10 o'clock, 12
o'clock and 2 o'clock for preclosure.
Second arterial access was obtained to the left common femoral artery with
micropuncture kit, modified Seldinger technique, and direct ultrasound
visualization and 6-French 45 cm Destination sheath was positioned through
the very tortuous iliac artery to the descending aorta over the 180 cm
SupraCore wire.
Then, with the SupraCore wire from the right femoral approach, we
positioned the JR4 catheter to the ascending aorta and exchanged the wire
to 300 cm double curve Lunderquist wire with a loop of the wire in the
aortic root. The JR4 catheter was removed. The 8-French sheath from the
right femoral was removed. Pre-dilatation with 12, 16, 20 and 22 dilator
was performed and then 22-French Gore sheath, 30 cm sheath, was advanced
under fluoroscopy control and positioned to the distal aorta over the
Lunderquist wire.
Then, the 5-French pigtail catheter was advanced from the left femoral
approach and positioned to the distal ascending aorta and the aortic arch
and aortogram obtained at 40-degree LAO projection with power injection.
The vessels were clearly identified.
Then, 0.035 Phillips intravascular ultrasound catheter was advanced over
the Lunderquist wire to the ascending aorta and pullback was performed and
intravascular ultrasound obtained.
INTRAVASCULAR ULTRASOUND FINDINGS: This intravascular ultrasound showed
that the wire was in the true lumen of the aorta. The aortic size
immediately distal to the left subclavian was x 28 mm with area of
661 mm2. The aortic measurements in the mid portion of the aortic
ulceration were 27 x 26 mm ulceration across its diameter was 16 mm.
Once all the orientation of the branches including left subclavian artery,
innominate artery, and position of the ulcer were confirmed, we advanced
the Gore 34 x 10 cm cTAG stent graft initially advanced beyond the
innominate artery, then slowly pulled it back and positioned immediately
distal to the origin of the left subclavian artery. It was 50 percent
deployed and then another aortogram was obtained, which confirmed
excellent position of the device and device was fully deployed. Prior to
full deployment, the pigtail was pulled in the abdominal aorta, after
deployment, it was advanced through the new stent graft again to the
aortic arch and confirmatory angiogram obtained, which showed excellent
stent expansion, position and apposition without any evidence of endoleak
and beyond the stent graft with excellent flow in the aorta.
The delivery system was removed. We then removed the 22-French sheath
from the right femoral artery and tightened the sutures. For the
procedure, the patient was heparinized with ACT more than 250. Heparin
was provided by cardiac anesthesia and it was partially reversed at the
end of the procedure. The Perclose sutures were tightened. There was no
residual bleeding from the right groin.
The 6-French 45 cm sheath was removed from the left femoral access and
6-French Angio-Seal closure device successfully deployed without any
residual bleeding.
Overall, estimated blood loss was about 100 mL
There were no immediate complications.
CONCLUSIONS:
1. Penetrating aortic ulcer, symptomatic.
2. Successful endovascular repair of the descending thoracic aorta not
involved in coverage of the left subclavian with 34 x 10 cm Gore
cTAG stent graft.
3. Large bore access to the right femoral artery with successful
preclosure.
4. Nonselective aortic catheter placement and radiologic supervision
and interpretation.
5. Intravascular ultrasound of the aortic arch and descending aorta.
6. The patient to continue his current therapy including aspirin.
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