embolization and angiography

Can someone please help with this? I don't do a lot of these, so I don't feel confident in it.

xx-year-old female status post endovascular repair of abdominal

aortic aneurysm in 2012, presents with recent CT demonstrating increased

sac size, without demonstrable endoleak. Reportedly the patient underwent

ultrasonography, that also failed to detect endoleak.

PRE-PROCEDURE DIAGNOSIS:

Status post endovascular repair of abdominal aortic aneurysm, occult

endoleak suspect.

POST-PROCEDURE DIAGNOSIS:

Same, type II endoleak.

PROCEDURES PERFORMED:

ABDOMINAL AORTOGRAPHY, CONE BEAM CTA ABDOMINAL AORTOGRAPHY, PELVIC ANGIOGRAPHY, RIGHT L4 LUMBAR ARTERY EMBOLIZATION

IMAGING MODALITY UTILIZED:

Ultrasound, fluoroscopy, cone beam CTA.

ANESTHESIA: Local.

ACCESS SITE:

Right common femoral artery.

CATHETER POSITION:

Abdominal aorta, right and left iliac limbs of the abdominal aortic

aneurysm endograft, right hypogastric artery, right iliolumbar artery,

right L4 lumbar artery, abdominal aortic aneurysm Endosac.

CONTRAST UTILIZED: Dilute Visipaque to minimize the risk of

nephrotoxicity.

TECHNIQUE: The right and left groins were sterilely prepped and draped in the standard fashion as described above. Under ultrasound guidance, after achieving local anesthesia with 1% lidocaine, the right common femoral artery was accessed. Over a guidewire, a 5 French sheath was inserted followed by

placement of a 5 French Omni Flush catheter positioned in the proximal

abdominal aorta. RAO abdominal aortography was performed. Catheter was

exchanged over the guidewire for a 5 French Reuter catheter. Reuter

catheter positioned in the left iliac limb. Injection performed. Catheter

positioned in the right iliac limb. Injection performed. Catheter

positioned in the right hypogastric artery, and injection performed. There

is a slightly prominent right iliolumbar to L4 lumbar artery that appears

to faintly spill into the Endosac. Subsequently, a coaxial 3 French

renegade GTC microcatheter was advanced over an 0.014 inch fathom guidewire into the right iliolumbar artery. Injections were performed. The catheter was further advanced into the right L4 lumbar artery. Injections

performed. Catheter was further advanced over the guidewire into the

Endosac. Injections performed. Small type II endoleak demonstrated.

Subsequently, the right L4 lumbar artery was embolized at the interface of

the abdominal aorta utilizing three Concerto detachable coils (1-4 mm x 10

cm, 1-3 mm x 4 cm, 1-2 mm x 4 cm). Endpoint was complete occlusion.

Microcatheter removed. Reuter catheter exchanged over a guidewire for a 5

French Omni Flush catheter placed in the proximal abdominal aorta. With

the catheter in this position, cone beam CTA was performed. No additional

endoleak was demonstrated. Catheter removed. Sheath removed. Assess site closed using StarClose.

Sterile dressing applied.

FINDINGS:

Patent Endurant abdominal aortic aneurysm endograft. Proximal and distal

seal zones appear intact. There is no type I endoleak demonstrated. There

is a small right L4 lumbar vertebral artery type II endoleak demonstrated

with selective catheterization of the right iliolumbar artery. This was

embolized as described above with Concerto detachable coils with complete

occlusion of the artery and post injection images demonstrating no type II

endoleak. Completion cone beam CTA demonstrates no endoleak, sac

perfusion. Selective injections into each iliac limb demonstrate no

evidence for limb failure or distal seal zone endoleak.

There is interval development of greater than 75% proximal right renal

artery stenosis. Endovascular intervention could be considered in this

patient with mild underlying renal insufficiency and hypertension.

COMPLICATIONS: None.

IMPRESSION:

ABDOMINAL AORTOGRAPHY, SELECTIVE ANGIOGRAPHY OF THE RIGHT HYPOGASTRIC

ARTERY DEMONSTRATES A SMALL TYPE II ENDOLEAK FROM THE RIGHT L4 LUMBAR

ARTERY. THIS IS EMBOLIZED WITH COILS USING A TRANSARTERIAL APPROACH WITH

COMPLETE OCCLUSION OF THE ENDOLEAK. THERE ALSO IS A GREATER THAN 75%

PROXIMAL RIGHT RENAL ARTERY STENOSIS IDENTIFIED, THIS HAS PROGRESSED FROM

THE IMAGES OBTAINED AT THE LEVEL OF THE ENDOVASCULAR REPAIR IN 2012.

CONSIDERATION FOR ENDOVASCULAR MANAGEMENT OF THE RIGHT RENAL ARTERY

STENOSIS IS SUGGESTED IN THIS PATIENT WITH HYPERTENSION AND RENAL

INSUFFICIENCY.

COMPLETION CONE BEAM CTA DEMONSTRATES NO EVIDENCE FOR ENDOLEAK.

I'm sure my codes aren't right, but here goes: I have 75625 for the abdominal aortography, 37242 for the embolization, 36247 for the cath placement in the right iliolumbar artery, 75710 for the injection in the left iliac limb, and 75774 x 3 for injections into the right iliac limb, right hypogastric artery, and right iliolumbar artery. I feel like I have too many 75774s. Opinions?? Thank you!

embolization and angiography