14, Number 92 > Issue 15,

Interventional Radiology Case Studies ≥ >> Table of Contents CASE 1..........................................1 UTERINE ARTERY PROCEDURES

CASE 2..........................................2

publications

| newsletters | seminars | webcasts

Yellow highlighted areas in the case studies are key phrases from the documentation used to help you arrive at the appropriate CPT® code(s) for the studies performed. Green highlighted areas in the case studies are key phrases from the documentation used to help you arrive at the appropriate ICD-9 code(s) for the studies performed.

GI TUBE CARE

CASE 3..........................................3

Blue highlighted areas in the case studies are areas where key phrases used to help you arrive at the appropriate CPT code(s) and ICD-9 code(s) overlap.

MESENTERIC ANGIOGRAPHY WITH POSSIBLE EMBOLIZATION

CASE 4..........................................4 MULTIPLE LEVEL VERTEBROPLASTY

CASE 1

CASE 5..........................................5 STEREOTACTIC GUIDED LEFT BREAST BIOPSY

HOW DID YOU DO?.....................6

NOW W

ITH

-1L0K ICD SSWA

>> www.panaceainc.com

CRO

UTERINE ARTERY PROCEDURES SUMMARY Uterine artery embolization performed for uterine AVM. TECHNIQUE/FINDINGS The patient was sterilely draped and prepped over the right groin with local anesthetic administered. Using a modified Seldinger technique, the right common femoral artery was accessed and a 5 Fr sheath placed. Through this, a 5 Fr Omni Flush catheter was placed into the lower abdominal aorta and formed Bentson wire was placed into the contralateral external iliac artery. Catheter was removed. Bookstein catheter was placed over the wire and formed. This was used to selectively catheterization the left internal iliac artery with contrast injection performed. Contrast injection demonstrated filling of the uterine artery with no significant filling of the AVM demonstrated on MRI. Bookstein catheter was used to catheterize the ostia of the right uterine artery and a Renegrade high-flow microcatheter was placed into the right uterine artery. Contrast injection at this point demonstrated that there was some spasm of the right uterine artery. Bookstein catheter was repositioned farther away from the ostia of the right uterine artery. Approximately 100mcg of nitroglycerin was instilled through the microcatheter and checked after two minutes with contrast injection. There was still vasospasm present, so 100mcg was instilled through the Bookstein catheter and with a third instillation of 100mcg of through the microcatheter. At this point, the was much better forward flow within the uterine artery. Embolization was performed with Embospheres 500 and 700 micron until stasis had been achieved. Stasis was confirmed with contrast injection. Microcatheter was removed and Bookstein catheter was repositioned into the left internal iliac artery. Contrast injection again demonstrated filling of the left uterine artery. However, this time, there was contrast communicating into the AVM. Microcatheter was then advanced distally within the left uterine artery with contrast injection confirming position. From this position, embolization was performed with Embospheres 500-700 micron until stasis had been achieved. Total of ½ vial was used on each side to obtain stasis. Once stasis was achieved, contrast injection confirmed this. Bookstein catheter was unformed and removed. Sheath was removed and manual hemostasis was obtained. Patient tolerated the procedure well with no immediate complications.

| CASE 1 ... continued on page 2 |

Interventional Radiology Case Studies | Issue 15, Number 9

|||

| CASE 1 ... continued from page 1 | PREPROCEDURE Patient seen, evaluated, history reviewed, and approach for sedation. Airway, heart, and lung exam satisfactory for sedation. Discussed risks, benefits, alternatives for procedure, and/or sedation, and obtained informed consent. Patient understands information and questions answered. Immediately prior to starting the procedure, in the presence of the assisting personnel, procedural pause was conducted to verify correct patient identity and verification of procedure to be performed, and as applicable, correct side and site, correct patient position, availability of implants, special

equipment, or special requirements, and all image and specimen identification data. Moderate sedation was administered by sedation nurse under my supervision. The roles and responsibilities of care team members, residents, and fellows were discussed. SEDATION TIME 65 minutes. FLUORO TIME 18.1 minutes.

CASE 2 GI TUBE CARE REASON FOR EXAM Per discussion with primary physician, modify or replace current PEG tube to jejunostomy re: regurgitation and aspiration; Other (Please Specify) REPORT Procedure Date and Time: 5/22/2015

A 75 cm .035 inch Amplatz guidewire was placed into the gastric lumen. The existing gastric tube was removed over the wire. A 25cm 6-French interventional sheath was placed over the wire. Access through the pylorus was achieved using a KMP catheter and a hydrophilic 0.035 inch glide wire. The glide wire was exchanged for a stiff hydrophilic glide wire which was then used catheterized the proximal jejunum distal to the ligament of Treitz. The KMP catheter and sheath removed over the wire.

COMPARISON STUDY Radiograph 5/21/15

A 20-French and dilator were placed over the wire into the gastric lumen to dilate the percutaneous tract. A 20-French sheath was removed. An 18-French peel-away sheath was placed over the wire. The dilator was removed. A 22-French transgastric jejunostomy single lumen feeding tube was placed over the wire into the gastric lumen as the peel-away sheath was removed.

REASON FOR STUDY Per discussion with Dr. A, modify or replace current PEG tube to jejunostomy re: regurgitation and aspiration

The GJ tube was not advancement beyond the pylorus. A second stiffened hydrophilic glide wire was placed via the gastric tube attempting to gain stability with which to advance the jejunostomy tube without success. The second wire was removed.

PROCEDURE Replace Gastro-Jejunostomy Tube Perc

TECHNIQUE Informed written consent obtained. Time out performed. The patient was placed supine on the interventional table in the left upper quadrant was cleansed and prepped in a sterile fashion. Scout radiograph demonstrates a percutaneous left upper quadrant endoscopically placed gastrostomy tube. 1% Xylocaine a 25-gauge needle used for local anesthesia. Infused contrast via the existing tube demonstrates luminal placement within the stomach without extravasation.

A 12 x 4 conquest balloon was placed over the wire and advanced beyond the tip of the jejunostomy tube. The balloon was inflated under continuous fluoroscopic guidance the dilating the pyloric stenosis. The balloon was partially deflated. The jejunal feeding tube and balloon catheter were advanced as a unit into the second portion the duodenum. The balloon was deflated and removed over the wire. The jejunal feeding tube was then advanced past the ligament of Treitz over the wire. The wire was removed. Infuse contrast demonstrates appropriate placement. The bulb was inflated with 8 mL of sterile water. The Molnar disk was approximated to the skin surface 10 anchored in place with a single 3-0 Ethilon suture.

| CASE 2 ... continued on page 3 | 2