margaret fahy
Guru
Opinions, please.....ANEURYSMAL BONE CYST SCLERO...WOULD IT BE 20615 OR 37241 OR 37243? The venograms are for roadmapping. Usually for a direct injxn. into an ABC, we'd use 20615 and guidance. We're not injecting the Sclerosant into the vein(s). Some say this is a tumor..so...37243 if a Sclero code is to be used? What codes do you guys recommend?
PROCEDURE: The right pelvic superior pubic ramus aneurysmal bone
cyst was examined with ultrasound and fluoroscopy and a suitable
access site for access placement was identified. The right hip
was prepared and draped in the usual sterile fashion. Using
ultrasound and fluoroscopic guidance, a 18 gauge needle was
advanced in a superolateral direction into a focal hypoechoic
portion of the right pelvic osseous lesion. Using Seldinger
technique, a 7 French sheath was placed. This process was
repeated for a total of 3 sheaths placed in different
orientations:
1. Superolateral course,
2. Inferomedial course,
3. Superoinferior course.
Initially slow, dark blood return was noted each sheath and
contrast was injected into each sheath which demonstrated
opacification different components of the right pelvic aneurysmal
bone cyst and relatively rapid outflow of contrast into pelvic
draining veins to the common femoral, internal and external iliac
veins.
Using ultrasound and fluoroscopic guidance, a 5 French catheter
was placed with the inferomedially oriented sheath, and this
region was injected with 2 mL of 45% n-BCA: lipiodol (glue)
dilution. Repeat contrast injection demonstrates reduced
opacification of the outflow veins. An initial cone beam CT
injection of contrast into all sheaths, to verify adequate
filling of all components. Adequate coverage was noted, but to
assist further filling of all components through septations,
disruption of septations was attempted with a Python balloon,
advanced into the inferomedially oriented sheath, and dilation of
the thin-walled ABC component was performed. Furthermore, a
0.035" stiff Glidewire was advanced through the sheaths for
further disruption of septations. Then, three 15 G trocars were
advanced in a different locations of the aneurysmal bone cyst
between the sheaths in order to act as "chimneys" for planned
sclerotherapy. After placement of these additional trochars,
better communication across all access point was noted.
Under ultrasound and fluoroscopic guidance, each region was
injected with Grafton-doxycycline mixture, consisting of 10 mL of
Grafton paced 10 mL of a 20 mg/mL doxycycline solution in
Omnipaque 300 (in total producing, 10 mg/mL of doxycycline in
Grafton). Injection was performed initially under careful roadmap
fluoroscopy to confirm the lack of venous outflow. Injection was
then bone with adjunct sonography, to treat all visible
components of the aneurysmal bone cyst. A repeat cone beam CT was
performed to confirm treatment of all components of the target. A
total of approximately 50 mL of the doxycycline-Grafton mixture
was administered ABC, accounting for approximate loss of 10 mL
through the chimneys.
Finally, Gelfoam pledgets were used to close each of the 3 sheath
accesses and each of the 3 metal cannula accesses. The skin was
cleaned and treated with antibiotic ointment. Then, access sites
were covered with a clean, sterile dressing. A final image was
taken of the chest. There were no immediate complications. The
patient tolerated the procedure appropriately and left the IR
suite in stable condition. Drs.... were
present for the entire procedure.
FINDINGS: Initial fluoroscopic image demonstrated similar
expansile mass of the right pelvis with thinned, expanded
cortical margins. Ultrasound reveals an osseous lesion with
internal heterogenous hypoechoic components. These regions were
specifically targeted for sclerotherapy. Ultrasound and
fluoroscopic images after contrast injection demonstrates
opacification of different segments of the region, all with
outflow of contrast via medium- to large-sized channels to the
right common femoral vein and, external iliac vein and internal
iliac vein. Subsequent fluoroscopic images demonstrated
appropriate filling of the inferomedially component with the
glue-lipiodol foam solution. Initial CT after sheath access
demonstrate glue and contrast filling of the ABC. Subsequent CT
after partial treatment demonstrates appropriate positioning of
the 6 accesses, with additional filling of the lesion with the
Grafton-doxycycline mixture. There were regions in the inferior
component and superficial/superior component that were less
opacified and subsequently targeted for treatment. Final
post-treatment ultrasound and fluoroscopic images revealed
appropriate distribution of the Grafton-doxycycline mixture
throughout the lesion.
Fluoroscopy confirmed non-migration of the sclerosant more
proximal than the target site. No skin discoloration was noted
at the end of the procedure. Final thoracic radiograph shows no
evidence of embolized material.
Fluoroscopic and sonographic guidance were used for this
procedure. Permanent ultrasound and fluoroscopic and C-arm CT
images were obtained and stored in the PACS.
IMPRESSION:
Successful sclerotherapy of the right superior pubic
ramus aneurysmal bone cyst.
PLAN: Possible overnight admission pending pain management
requirements, and follow up in IR clinic.
PROCEDURE: The right pelvic superior pubic ramus aneurysmal bone
cyst was examined with ultrasound and fluoroscopy and a suitable
access site for access placement was identified. The right hip
was prepared and draped in the usual sterile fashion. Using
ultrasound and fluoroscopic guidance, a 18 gauge needle was
advanced in a superolateral direction into a focal hypoechoic
portion of the right pelvic osseous lesion. Using Seldinger
technique, a 7 French sheath was placed. This process was
repeated for a total of 3 sheaths placed in different
orientations:
1. Superolateral course,
2. Inferomedial course,
3. Superoinferior course.
Initially slow, dark blood return was noted each sheath and
contrast was injected into each sheath which demonstrated
opacification different components of the right pelvic aneurysmal
bone cyst and relatively rapid outflow of contrast into pelvic
draining veins to the common femoral, internal and external iliac
veins.
Using ultrasound and fluoroscopic guidance, a 5 French catheter
was placed with the inferomedially oriented sheath, and this
region was injected with 2 mL of 45% n-BCA: lipiodol (glue)
dilution. Repeat contrast injection demonstrates reduced
opacification of the outflow veins. An initial cone beam CT
injection of contrast into all sheaths, to verify adequate
filling of all components. Adequate coverage was noted, but to
assist further filling of all components through septations,
disruption of septations was attempted with a Python balloon,
advanced into the inferomedially oriented sheath, and dilation of
the thin-walled ABC component was performed. Furthermore, a
0.035" stiff Glidewire was advanced through the sheaths for
further disruption of septations. Then, three 15 G trocars were
advanced in a different locations of the aneurysmal bone cyst
between the sheaths in order to act as "chimneys" for planned
sclerotherapy. After placement of these additional trochars,
better communication across all access point was noted.
Under ultrasound and fluoroscopic guidance, each region was
injected with Grafton-doxycycline mixture, consisting of 10 mL of
Grafton paced 10 mL of a 20 mg/mL doxycycline solution in
Omnipaque 300 (in total producing, 10 mg/mL of doxycycline in
Grafton). Injection was performed initially under careful roadmap
fluoroscopy to confirm the lack of venous outflow. Injection was
then bone with adjunct sonography, to treat all visible
components of the aneurysmal bone cyst. A repeat cone beam CT was
performed to confirm treatment of all components of the target. A
total of approximately 50 mL of the doxycycline-Grafton mixture
was administered ABC, accounting for approximate loss of 10 mL
through the chimneys.
Finally, Gelfoam pledgets were used to close each of the 3 sheath
accesses and each of the 3 metal cannula accesses. The skin was
cleaned and treated with antibiotic ointment. Then, access sites
were covered with a clean, sterile dressing. A final image was
taken of the chest. There were no immediate complications. The
patient tolerated the procedure appropriately and left the IR
suite in stable condition. Drs.... were
present for the entire procedure.
FINDINGS: Initial fluoroscopic image demonstrated similar
expansile mass of the right pelvis with thinned, expanded
cortical margins. Ultrasound reveals an osseous lesion with
internal heterogenous hypoechoic components. These regions were
specifically targeted for sclerotherapy. Ultrasound and
fluoroscopic images after contrast injection demonstrates
opacification of different segments of the region, all with
outflow of contrast via medium- to large-sized channels to the
right common femoral vein and, external iliac vein and internal
iliac vein. Subsequent fluoroscopic images demonstrated
appropriate filling of the inferomedially component with the
glue-lipiodol foam solution. Initial CT after sheath access
demonstrate glue and contrast filling of the ABC. Subsequent CT
after partial treatment demonstrates appropriate positioning of
the 6 accesses, with additional filling of the lesion with the
Grafton-doxycycline mixture. There were regions in the inferior
component and superficial/superior component that were less
opacified and subsequently targeted for treatment. Final
post-treatment ultrasound and fluoroscopic images revealed
appropriate distribution of the Grafton-doxycycline mixture
throughout the lesion.
Fluoroscopy confirmed non-migration of the sclerosant more
proximal than the target site. No skin discoloration was noted
at the end of the procedure. Final thoracic radiograph shows no
evidence of embolized material.
Fluoroscopic and sonographic guidance were used for this
procedure. Permanent ultrasound and fluoroscopic and C-arm CT
images were obtained and stored in the PACS.
IMPRESSION:
Successful sclerotherapy of the right superior pubic
ramus aneurysmal bone cyst.
PLAN: Possible overnight admission pending pain management
requirements, and follow up in IR clinic.