margaret fahy
Guru
Opinions on this one? Prospective codes...two opinions.... 37248, 37249, 36010, 75825, 36011, 75889, 76937... OR... 37248, 36010, 76937...ONLY. PROCEDURE: Limited ultrasound of the right neck was performed to identify the right internal jugular vein and asses patency. The skin of the right neck was prepped and draped in sterile fashion using DuraPrep. After local anaesthesia with 0.2% ropivacaine, a 21-gauge needle was inserted into the right internal jugular vein with ultrasound guidance with special attention to avoid indwelling catheter. A 0.018" wire was advanced under fluoroscopic guidance to the IVC. A 5 Fr micropuncture sheath was advanced over the wire and a 0.035" Bentson wire was advanced into the IVC. The tract was dilated and an 8 French vascular sheath was advanced into the right internal jugular vein. A 5 French Berenstein catheter was advanced over the wire to the inferior vena cava below the level of an indwelling stent. The wire was removed, and an inferior venacavogram was performed. Over a Bentson wire, a 16 mm x 4 cm Atlas Gold balloon was advanced and angioplasty of the central IVC just proximal to the stent was performed. The balloon catheter was exchanged over the wire for the Berenstein catheter which was advanced into IVC beyond the stent, and a post-angioplasty inferior venacavogram was performed. Pressures were obtained. Using a Bentson wire and Berenstein catheter the confluence of the middle and left hepatic veins was selected. Venography was performed and pressures were obtained. Balloon angioplasty was performed of this segment with the 12 mm x 4 cm Conquest balloon x 3. Pressures were obtained. Post-angioplasty hepatic venography was performed. All catheters and wires were removed. The sheath was removed without dislodging the indwelling central venous catheter, and manual pressure was held over the right internal jugular vein access site until hemostasis was achieved. Steri-Strips and a sterile occlusive dressing were placed over the venous access site..........FINDINGS: Preintervention IVC venography demonstrates mild stenosis of the IVC cranial to the stent. There is rapid contrast flow through the stent and IVC. Repeat IVC venography following venoplasty cranial to the stent demonstrated improved caliber of the segment with brisk flow of contrast centrally. As before there is narrowing of the caudal end of the stent, best seen on the preceding CT. Manipulation of this area was avoided given known communication with the contained perforation (air often seen within stent) and nonresponse to prior venoplasty. In addition, there was no pressure gradient across the narrowing. Post intervention pressure measurements were as follows: Caudal to IVC stent: 7 mmHg Intrastent: 8 mmHg. Cranial to the stent: 6 mmHg. Initial venography of the left hepatic vein demonstrated a severe narrowing with reflux of contrast into the middle and left hepatic veins. Repeat venography following venoplasty demonstrated improved caliber with brisk flow of contrast centrally. Pre intervention pressure measurement of left hepatic vein: 13 mmHg (pressure gradient of 7 mmHg) Post intervention pressure measurements of the left hepatic vein: 8 mmHg (pressure gradient of 2 mmHg) Ultrasound demonstrated a patent and compressible right internal jugular vein. Permanent images stored in PACS. . Thanks so much.....Margie