bhargavi
Guru
Conclusion
This patient with prior treatment for substance abuse presented with progressively worsening dyspnea ongoing for last 3 to 4 weeks. He has also been noticing right lower extremity swelling. CT angiogram of chest revealed bilateral PE and lower extremity ultrasound revealed bilateral DVTs more prominent in the right lower extremity. Interventional cardiology consultation was requested for thrombectomy.
After obtaining informed consent, the patient was prepped and draped in sterile fashion. A 6 French was inserted in right common femoral vein. A 6 French Swan catheter was used to perform right heart catheterization. Figure-of-eight stitch was applied to the left common femoral vein access site for hemostasis.
I attest that moderate conscious sedation was provided under my direct supervision with the sedation trained nurse using 1 mg of intravenous Versed and 50 mcg of fentanyl to sedate the patient. Start time 11:58 AM and end time was 2 PM. There were no complications. See nurse's sedation sheet, for complete pre-and post service details.
Hemodynamics:
Right heart catheterization:
Prethrombectomy PA 85/25 with mean of 50 mm Hg.
Post thrombectomy PA 54/28 with mean of 38 mmHg.
Pulmonary tree angiography:
Post thrombectomy pulmonary angiography was performed and there was significant improvement in thrombus burden.
The patient was then transferred to the recovery area in stable condition:
Summary conclusion:
1. Bilateral PE
2. Pulmonary Hypertension
3. Bilateral lower extremity DVT
Recommendation:
Recommend manual thrombectomy.
A 6 French sheath was inserted in left common femoral vein. A 6 French Arrow catheter was used to perform right heart catheterization using a 300 cm V18 wire for additional support. V18 wire was advanced into left pulmonary tree. Swan catheter was removed and exchanged for 110 cm angled glide catheter which was advanced into left pulmonary tree. 260 cm Amplatz Super Stiff wire was advanced into left pulmonary tree. Glide catheter was removed and a 24 French sheath was inserted in left common femoral vein. Patient received 7000 units of IV heparin. Inari T24 catheter was advanced into left pulmonary tree and significant amount of clot was removed. Next we advanced a angled pigtail catheter through the Inari T24 catheter. V18 wire was advanced into the right pulmonary tree using the pigtail catheter. Pigtail catheter was removed and exchanged for 150 cm angled glide catheter which was positioned deep into right pulmonary tree. V18 wire was removed and exchanged for a 260 cm Amplatz Super Stiff wire which was positioned deep into the right pulmonary tree. Glide cath was removed and Inari T24 catheter was advanced into right pulmonary tree. Manual thrombectomy was performed and significant amount of clot was removed. Final ACT was measured at 266. Catheters were removed and figure-of-eight stitch was applied to the left common femoral vein access for hemostasis.
Start IV heparin infusion. Transition to oral NOAC prior to discharge.
Recommend thrombectomy of right lower extremity DVT.
thanks in advance
should i bill 37184, 37185?
can i add 50 modifier for bilateral?
This patient with prior treatment for substance abuse presented with progressively worsening dyspnea ongoing for last 3 to 4 weeks. He has also been noticing right lower extremity swelling. CT angiogram of chest revealed bilateral PE and lower extremity ultrasound revealed bilateral DVTs more prominent in the right lower extremity. Interventional cardiology consultation was requested for thrombectomy.
After obtaining informed consent, the patient was prepped and draped in sterile fashion. A 6 French was inserted in right common femoral vein. A 6 French Swan catheter was used to perform right heart catheterization. Figure-of-eight stitch was applied to the left common femoral vein access site for hemostasis.
I attest that moderate conscious sedation was provided under my direct supervision with the sedation trained nurse using 1 mg of intravenous Versed and 50 mcg of fentanyl to sedate the patient. Start time 11:58 AM and end time was 2 PM. There were no complications. See nurse's sedation sheet, for complete pre-and post service details.
Hemodynamics:
Right heart catheterization:
Prethrombectomy PA 85/25 with mean of 50 mm Hg.
Post thrombectomy PA 54/28 with mean of 38 mmHg.
Pulmonary tree angiography:
Post thrombectomy pulmonary angiography was performed and there was significant improvement in thrombus burden.
The patient was then transferred to the recovery area in stable condition:
Summary conclusion:
1. Bilateral PE
2. Pulmonary Hypertension
3. Bilateral lower extremity DVT
Recommendation:
Recommend manual thrombectomy.
A 6 French sheath was inserted in left common femoral vein. A 6 French Arrow catheter was used to perform right heart catheterization using a 300 cm V18 wire for additional support. V18 wire was advanced into left pulmonary tree. Swan catheter was removed and exchanged for 110 cm angled glide catheter which was advanced into left pulmonary tree. 260 cm Amplatz Super Stiff wire was advanced into left pulmonary tree. Glide catheter was removed and a 24 French sheath was inserted in left common femoral vein. Patient received 7000 units of IV heparin. Inari T24 catheter was advanced into left pulmonary tree and significant amount of clot was removed. Next we advanced a angled pigtail catheter through the Inari T24 catheter. V18 wire was advanced into the right pulmonary tree using the pigtail catheter. Pigtail catheter was removed and exchanged for 150 cm angled glide catheter which was positioned deep into right pulmonary tree. V18 wire was removed and exchanged for a 260 cm Amplatz Super Stiff wire which was positioned deep into the right pulmonary tree. Glide cath was removed and Inari T24 catheter was advanced into right pulmonary tree. Manual thrombectomy was performed and significant amount of clot was removed. Final ACT was measured at 266. Catheters were removed and figure-of-eight stitch was applied to the left common femoral vein access for hemostasis.
Start IV heparin infusion. Transition to oral NOAC prior to discharge.
Recommend thrombectomy of right lower extremity DVT.
thanks in advance
should i bill 37184, 37185?
can i add 50 modifier for bilateral?