amrcpc
Contributor
I coded 37215 and 37186 because the thrombectomy was performed after the stent placement ...is this correct?
EXAM:
Cerebral angiogram with carotid stent placement and mechanical thrombectomy.
CLINICAL HISTORY an indication:
Patient is a 65 yo female, presents as a transfer from outside hospital with acute stroke symptoms. Patient is referred for emergent thrombectomy.
PROCEDURE COMMENT:
A two physician emergency consent was performed. Multiple attempts were made to contact the family members.
Sedation: Moderate conscious sedation was provided for the procedure and the patient was monitored by a nurse trained in physiologic monitoring. Sedation time was 48 minutes.
The right groin was prepared using a sterile technique and a right common femoral artery puncture was done to gain access using a 8F sheath which was connected to saline flush. The 5-French Davis catheter and the guidewire were used to select the left
common carotid artery and the neuron max guiding catheter was placed in the common carotid artery.
FINDINGS:
Left common carotid angiogram was performed demonstrating severe stenosis at the left carotid bifurcation with severe proximal left internal carotid stenosis.
Left common carotid angiogram was performed centered over the brain demonstrating moderate to severe irregular multifocal stenosis of the distal internal carotid artery. There was occlusion of the M1 segment of the middle cerebral artery. The A1
segment of the left anterior cerebral artery is patent. The A2 segments are patent and there are pial collaterals to the left MCA territory.
INTERVENTION:
The Emboshield embolic protection device was then advanced beyond the level of the left carotid stenosis. An 8 mm x 21 mm carotid wall stent was then delivered to the level of the stenosis and deployed. Follow-up angiogram demonstrated significant
improvement in the stenosis. The embolic protection device was retrieved. Follow-up angiogram demonstrated significant radiographic improvement in the left internal carotid artery stenosis.
Due to the moderate to severe distal left internal carotid artery stenosis, it would not be possible to advance the aspiration thrombectomy catheter to the level of the MCA occlusion. It was decided to perform mechanical thrombectomy using the Solitaire
stent retriever device. The velocity microcatheter was advanced beyond the level of the left MCA occlusion. TheSolitaire stent retriever device was deployed at the level of the occlusion. The device was removed. A follow-up angiogram demonstrated
reconstituted flow within the M1 segment and some of the M2 branches. There was restoration of TICI 2a flow. There was persistent occlusion in some of the M2 branches. The risks advancing the stent retriever device across the multifocal carotid
stenosis and the newly placed stent outweighed the potential benefits. No further intervention was performed.
An angiogram was performed through the sheath demonstrating an access site appropriate for closure device. Hemostasis was obtained in the right groin using the Perclose device.
The total contrast dose for the procedure was: 85 cc of Visipaque.
The total radiation dose was approximately: 8209 cGycm2.
EXAM:
Cerebral angiogram with carotid stent placement and mechanical thrombectomy.
CLINICAL HISTORY an indication:
Patient is a 65 yo female, presents as a transfer from outside hospital with acute stroke symptoms. Patient is referred for emergent thrombectomy.
PROCEDURE COMMENT:
A two physician emergency consent was performed. Multiple attempts were made to contact the family members.
Sedation: Moderate conscious sedation was provided for the procedure and the patient was monitored by a nurse trained in physiologic monitoring. Sedation time was 48 minutes.
The right groin was prepared using a sterile technique and a right common femoral artery puncture was done to gain access using a 8F sheath which was connected to saline flush. The 5-French Davis catheter and the guidewire were used to select the left
common carotid artery and the neuron max guiding catheter was placed in the common carotid artery.
FINDINGS:
Left common carotid angiogram was performed demonstrating severe stenosis at the left carotid bifurcation with severe proximal left internal carotid stenosis.
Left common carotid angiogram was performed centered over the brain demonstrating moderate to severe irregular multifocal stenosis of the distal internal carotid artery. There was occlusion of the M1 segment of the middle cerebral artery. The A1
segment of the left anterior cerebral artery is patent. The A2 segments are patent and there are pial collaterals to the left MCA territory.
INTERVENTION:
The Emboshield embolic protection device was then advanced beyond the level of the left carotid stenosis. An 8 mm x 21 mm carotid wall stent was then delivered to the level of the stenosis and deployed. Follow-up angiogram demonstrated significant
improvement in the stenosis. The embolic protection device was retrieved. Follow-up angiogram demonstrated significant radiographic improvement in the left internal carotid artery stenosis.
Due to the moderate to severe distal left internal carotid artery stenosis, it would not be possible to advance the aspiration thrombectomy catheter to the level of the MCA occlusion. It was decided to perform mechanical thrombectomy using the Solitaire
stent retriever device. The velocity microcatheter was advanced beyond the level of the left MCA occlusion. TheSolitaire stent retriever device was deployed at the level of the occlusion. The device was removed. A follow-up angiogram demonstrated
reconstituted flow within the M1 segment and some of the M2 branches. There was restoration of TICI 2a flow. There was persistent occlusion in some of the M2 branches. The risks advancing the stent retriever device across the multifocal carotid
stenosis and the newly placed stent outweighed the potential benefits. No further intervention was performed.
An angiogram was performed through the sheath demonstrating an access site appropriate for closure device. Hemostasis was obtained in the right groin using the Perclose device.
The total contrast dose for the procedure was: 85 cc of Visipaque.
The total radiation dose was approximately: 8209 cGycm2.
