critiquing random CCSVI procedure found in billing forum....
Posted: Mon Aug 22, 2011 9:33 pm
www.aapc.com/memberarea/forums/showthread.php?t=42564
PRE DIAGNOSIS: Central venous occlusive disease
POST DIAGNOSIS: Same
DETAILS OF PROCEDURE:
EKG was interpreted throughout the procedure. The left groin was prepped and draped. An 8F sheath was placed and a catheter was used to select the right IJ. A venogram was performed which showed a diffuse narrowing within the mid portion of the vein and a 50% stenosis at the level of the valve inferiorly. An 8mm balloon was initially used to treat both portions of the IJ with no improvement. Thus a 10mm balloon was also used with a waist that resolved upon full inflation of the balloon at the level of the valve. However, the mid portion of the jugular was still had a 90% stenosis.
The left internal jugular vein was then selectively catheterized. A venogram was performed which showed findings similar to the MRV performed yesterday. The IJ from the skull base to the lower neck was very small in caliber with an equally sized collateral running parallel to it into the skull base. Both were approximately 5-6mm in diameter. In the lower neck, the IJ and it’s collateral joined and the IJ was approximately 10mm with a 50% stenosis at the level of the inlet to the subclavian vein. The flow through the IJ system was very minimal and slow due to the small caliber throughout. To treat the valve region a 10mm balloon was used with a residual waist so a 12mm balloon was used. A residual waste was seen so a high pressure Conquest balloon was used to treat the valve with resolution of the waist. Repeat venogram showed residual slow flow through the IJ system. A small amount of intimal disruption but no extravastation was seen within the venoplasty region so 5000U of heparin were given.
A Cobra catheter was used to catheterize the Azygus vein and venogram was performed. No evidence of disease was seen with rapid antegrade flow throughout the vein. Thus the catheter was removed.
The RIJ was re-examined and venogram showed residual 90% mid stenosis with significant collateral flow. Thus despite aggressive angioplasty, recoil was present. A 14mm x 6cm Zilver uncovered stent was deployed across the lesion and completion venogram showed rapid antegrade flow with no collaterals.
The LIJ was selected and venogram showed stagnant flow due to residual stenosis at the inferior portion. A small amount of thrombus could not be ruled out so 2mg of tPA was given in that region. Further angioplasty with the 12mm balloon was also performed. Completion venogram showed a small amount of mobile filling defects but with antegrade flow.
IMPRESSION: Central venous occlusive disease. RIJ mid stenosis treated with 10mm PTA and ultimately a 14mm x 6cm stent. Left IJ small in caliber as described above. Inferior portion treated with 10 and 12mm balloon. Intimal disruption and subsequent filling defects. Ultimately resultant antegrade flow with small intra luminal filling defects. Normal Azygus vein.
PLAN: Pt will be given a prescription for lovenox to take for the next several days to allow the intimal tear to heal within the left IJ. Pt will see me in the office tomorrow for ultrasound to ensure no evidence of DVT.