Practice Chart 1
Indication: Lower GI bleeding
TECHNIQUE: Informed consent was obtained. The right common femoral artery was catheterized using a modified Seldinger technique and a micropuncture set. A 5 French sheath was inserted. Through this a 4 French Motarjamie catheter was used to select the inferior mesenteric artery. The mesenteric arteriogram was performed with multiple images over the distribution of the IMA. None of these demonstrated the suspected bleeding source. The catheter was then positioned in the SMA and superior mesenteric arteriograms performed. Again, no bleeding site was identified. Therefore, the procedure was terminated and the catheter removed and hemostasis obtained at the puncture site with the aid of a Star close device.
FLUOROSCOPY TIME: 12.6 minutes of fluoroscopy time.
CONTRAST: 90 mL isovue 300
POST OPERATIVE DIAGNOSIS: No bleeding site identified.
FINDINGS: The right hepatic artery is replaced to the SMA. The SMA injection does not show any significant abnormality. Specifically, no bleeding site is identified. Likewise, selective injection into the IMA fails to demonstrate any bleeding source. Dense vascular calcification is present in the aorta and iliac arteries and the iliac arteries are rather ectatic. The celiac artery was not injected because the patient had lower GI bleeding only.
IMPRESSION:No active bleeding at the time of this study.
CPT: 36245, 36245-59, 75726, 75726-59
Rationale: In above chart the visceral arteries are selectively catheterized and diagnostic angiography are performed. In the report, first IMA artery is selected (36245) and studied by performing an angiogram(75726), then SMA artery was selected (36245) and again an angiogram was perfromed (75726). Hence, the cpt codes should be 36245 for IMA artery and another 36245 for SMA. Same goes with supervision and interpretation for SMA (75726) and IMA (75726). Modifier 59 is used with cpt code just to differentiate that it is different procedure from another procedure.
Practice Chart 2
INDICATION/DIAGNOSIS: Esophageal varix hemorrhage. Hypotension.
CONTRAST: 50 cc Isovue-370
SEDATION: Intubated, general anesthesia.
PROCEDURE: Informed consent was obtained from the patient’s wife. He was positioned supine on the fluoroscopy table and the right neck was prepped and draped in the standard and sterile fashion. Ultrasound was used to identify the right internal jugular vein which was shown to be widely patent. An image was saved for the record and transferred to PACS. A small incision was made in the neck and a micropuncture needle was advanced into the right internal jugular vein. A microwire was advanced centrally over which a microsheath was placed. A wire was advanced into the hepatic vein. The venotomy was dilated and a angled tip TIPS sheath was placed over the wire. Another right internal jugular venous access was obtained in a similar fashion. Catheter was positioned in the inferior vena cava and the intravascular ultrasound device was advanced through the second sheath. The angled metal cannula was advanced to the tip of the sheath. With intravascular ultrasound guidance the cannula was turned anteriorly and the microneedle was advanced into the it was in a branch of the right portal vein. The inner stylette was removed and blood was aspirated. Digital subtraction portal venogram performed. An attempt was made to pass a V 18 wire into the main portal vein without success. The wire and sheath were repositioned in the middle hepatic vein. Using endovascular ultrasound the angled metal cannula was oriented towards the left portal vein just beyond the bifurcation. The 18 wire was advanced into the main portal vein and the tract was dilated with a 4 mm balloon. A multipurpose angled catheter was advanced into the main portal vein and digital subtraction venogram was performed. Pressures were measured in the right atrium and in the portal vein. An Amplatz wire was advanced into the main portal vein and the sheath was advanced over the wire. A multi marker pigtail catheter was advanced and portal venogram repeated. With the sheath in the main portal vein the Vytorin stent graft was advanced and deployed. The stent graft was dilated with an 8 mm balloon. Post TIPS venogram performed. Due to minimal persistent filling of the large coronary vein, a Glidewire was advanced into the coronary vein followed by a multipurpose angled catheter. Venogram performed. The branch was then embolized with 2 10 mm Nester coils. Post embolization venogram performed. Post TIPS pressures were measured in the portal vein and the right atrium. The sheaths were removed and hemostasis obtained with compression. Patient remained stable throughout the procedure and was transferred in stable condition from the angiography suite.Findings: Widely patent right internal jugular vein shown with ultrasound. An image was saved for the record and transferred to PACS. Initial right portal venogram shows conventional anatomy. Initial pre TIPS left portal venogram shows a very large left portal vein with punctured just beyond the bifurcation of the main portal vein. Main portal venogram shows a very large coronary varix and a large diameter main portal vein with otherwise conventional anatomy. Pre TIPS right atrial pressure 11 mmHg. Pre TIPS portal pressure measured at 28 mmHg for an initial gradient of 17 mmHg. Post TIPS right atrial pressure 16 mmHg. Post TIPS portal venogram measuring 21 mmHg for a post TIPS gradient of 5 mmHg. Post TIPS portal venogram shows brisk flow through the portal systemic shunt with only minimal flow into the proximal portion of the coronary vein. Selective coronary vein venogram shows large coronary varix with some flow towards the esophageal varices. Post embolization shows no further cranial flow within the coronary varix.
FLUOROSCOPY TIME: 23 minutes of fluoroscopy time was used.
- Successful placement of a transhepatic portal-systemic shunt. A 7 cm long Viatorr stent graft was deployed from the middle hepatic vein to the left portal vein just beyond the portal vein bifurcation. It was dilated with an 8 mm balloon. Pre TIPS portal-systemic gradient was 17 mmHg. Post TIPSS gradient measured at 5 mmHg.
- Successful coil embolization of large coronary varix with 2 10 mm Nester coils.
CPT : 36011, 75891, 76937
Practice chart 3
POSTOPERATIVE DIAGNOSIS: Same.
CONSENT: The procedure, risks, indications and alternatives were explained via phone to the patient’s husband, who has medical power of attorney. All questions were answered and informed consent was obtained, signed and witnessed from the patient..
TECHNIQUE: The patient was under constant monitor with her ICU nurse present during the entire procedure. Ultrasound localization of the fluid was performed. The abdomen was prepped and draped in the usual sterile fashion. Local anesthesia was obtained with 1% lidocaine. The ascitic fluid was accessed under direct ultrasound visualization with a 5F Yueh catheter in the right lower quadrant. Using a closed system the peritoneal fluid was aspirated. 1900 mL was obtained. The fluid was sent to the lab for analysis.
FINDINGS: Ultrasound appearance of the fluid was simple. The fluid was serosanguineous.
SPECIMENS: Approximately 50 ml was collected for labs and given to the patient’s nurse.
- Successful ultrasound-guided paracentesis.