bhargavi
Guru
Pre-operative Diagnosis: Type II endoleak of aortic graft [I97.89]
Post-operative Diagnosis: Same
Operation: Procedure(s):
1. Aortogram with bilateral iliac runoff.
2. Pelvic angiogram with third order selective vessel catheterization (posterior division internal iliac artery).
3. Ultrasound-guided right common femoral artery access with Mynx closure.
4. Interpretation of vascular imaging.
Specimens: None
Indications and Findings: The patient is a 79 y.o. male history of AAA status post EVAR. Surveillance cross-sectional imaging demonstrated a type II endoleak with interval enlargement of the aneurysm sac. In order to rule out an occult 1A/1B, or type III endoleak and potentially address the type II endoleak the patient was taken for an aortogram with possible intervention.
Findings:
No type Ia/Ib, nor 3 endoleak's.
Type II endoleak emanating from a right lumbar artery with poorly visualized egressed from the aneurysm sac, perhaps from a lower left lumbar artery.
Procedure Details:
The patient identified in the preoperative holding area and marked. He was brought into the operating room, positioned on the table supine with all pressure points padded. General LMA anesthesia was established without any difficulty. Bilateral groins were prepped chlorhexidine and sterilely draped. A timeout was performed which the patient, procedure and laterality were correctly verified.
Under ultrasound guidance, the right common femoral artery was accessed using micropuncture needle. Over an 035 Bentson wire a 5 French sheath was inserted and flushed. The Omni Flush cath was advanced to the infrarenal abdominal aorta. With the catheter placed at the level of the active-fixation of the graft and prolonged aortogram was performed. This identified no type Ia endoleak. This was performed in several obliquities. The catheter was then pulled into the main body of the aortic stent graft. Repeat aortogram did not show any evidence of a type III endoleak. Furthermore, no type Ib endoleak were appreciated.
On further prolonged angiography, we did appreciate a delayed type II endoleak likely emanating from right lumbar artery at the level of the flow divider with grass from the sac via an undetermined, and perhaps left lower lumbar artery. Over an 035 wire, we upsized the sheath to a 6 French by 25 cm sheath and the patient was systemically heparinized with 8000 units of heparin. Using several 014 and 018 wire and catheter combinations attempts were made to advance a wire in between the right iliac limb and native iliac artery. This was unsuccessful. After this, the right internal iliac artery was selected using a 035 Glidewire and Kumpe catheter. The catheter was advanced into the posterior division. Selective angiography through the catheter did not identify the previously seen endoleak. The catheter was withdrawn to the nearly the level of the origin of the internal iliac artery and repeat angiogram performed there was faint visualization of a blush within the aneurysm sac from several lumbar arteries which were not clearly identified. At this time, we elected to conclude the procedure. All wires and catheters removed from the patient intact. Right common femoral access was closed using this 6 French Mynx device. The patient tolerated procedure well. He was emerged from anesthesia without any difficulty and was transferred to PACU in stable condition.
thanks in advance
i only u/s 76937, 36247 rest i am not comingup with any codes. pl help. new to this type of coding
Post-operative Diagnosis: Same
Operation: Procedure(s):
1. Aortogram with bilateral iliac runoff.
2. Pelvic angiogram with third order selective vessel catheterization (posterior division internal iliac artery).
3. Ultrasound-guided right common femoral artery access with Mynx closure.
4. Interpretation of vascular imaging.
Specimens: None
Indications and Findings: The patient is a 79 y.o. male history of AAA status post EVAR. Surveillance cross-sectional imaging demonstrated a type II endoleak with interval enlargement of the aneurysm sac. In order to rule out an occult 1A/1B, or type III endoleak and potentially address the type II endoleak the patient was taken for an aortogram with possible intervention.
Findings:
No type Ia/Ib, nor 3 endoleak's.
Type II endoleak emanating from a right lumbar artery with poorly visualized egressed from the aneurysm sac, perhaps from a lower left lumbar artery.
Procedure Details:
The patient identified in the preoperative holding area and marked. He was brought into the operating room, positioned on the table supine with all pressure points padded. General LMA anesthesia was established without any difficulty. Bilateral groins were prepped chlorhexidine and sterilely draped. A timeout was performed which the patient, procedure and laterality were correctly verified.
Under ultrasound guidance, the right common femoral artery was accessed using micropuncture needle. Over an 035 Bentson wire a 5 French sheath was inserted and flushed. The Omni Flush cath was advanced to the infrarenal abdominal aorta. With the catheter placed at the level of the active-fixation of the graft and prolonged aortogram was performed. This identified no type Ia endoleak. This was performed in several obliquities. The catheter was then pulled into the main body of the aortic stent graft. Repeat aortogram did not show any evidence of a type III endoleak. Furthermore, no type Ib endoleak were appreciated.
On further prolonged angiography, we did appreciate a delayed type II endoleak likely emanating from right lumbar artery at the level of the flow divider with grass from the sac via an undetermined, and perhaps left lower lumbar artery. Over an 035 wire, we upsized the sheath to a 6 French by 25 cm sheath and the patient was systemically heparinized with 8000 units of heparin. Using several 014 and 018 wire and catheter combinations attempts were made to advance a wire in between the right iliac limb and native iliac artery. This was unsuccessful. After this, the right internal iliac artery was selected using a 035 Glidewire and Kumpe catheter. The catheter was advanced into the posterior division. Selective angiography through the catheter did not identify the previously seen endoleak. The catheter was withdrawn to the nearly the level of the origin of the internal iliac artery and repeat angiogram performed there was faint visualization of a blush within the aneurysm sac from several lumbar arteries which were not clearly identified. At this time, we elected to conclude the procedure. All wires and catheters removed from the patient intact. Right common femoral access was closed using this 6 French Mynx device. The patient tolerated procedure well. He was emerged from anesthesia without any difficulty and was transferred to PACU in stable condition.
thanks in advance
i only u/s 76937, 36247 rest i am not comingup with any codes. pl help. new to this type of coding