embolization help--new to me

Please help!
Dr Reported
36222x1
36224x1
36226x1
75894
36200

I think:
36224
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61624
75894
75898x7

ICD Codes / Adm.Diagnosis: 437.3 437.3 / Cerebral aneurysm, nonruptured

Cerebral aneurysm, nonruptur

Examination: XA CAROTID CRBRL W CATH LT -

Accession No:

Reason: cerebral aneurysm

REPORT:

CLINICAL INDICATION: Left anterior cerebral artery aneurysm for

endovascular treatment.

OPERATORS:

CONTROL ANGIOGRAMS: 7

COMPLICATIONS: None.

GENERAL ANESTHESIA: Pre-procedure evaluation confirmed that the patient was

an appropriate candidate for general anesthesia. Adequate anesthesia was

maintained during the entire procedure by the anesthesia team. Vital signs

and pulse oximetry were monitored and recorded by the anesthetist throughout

the procedure and the recovery period. The flow sheet was placed in the

medical record including the medications and dosages used. No immediate

anesthesia related complications were noted.

PRE-PROCEDURE: The patient was seen and examined. The chart and images were

reviewed. I had a lengthy discussion with the patient and/or their family

regarding the disease process, as well as potential treatment options, which

include medical management, surgical treatment, or endovascular treatment.

The risks, benefits, and alternatives to the procedure were explained to the

patient and/or the family, and written informed consent was obtained.

PROCEDURE: A Time-Out was performed prior to the procedure to confirm the

patient's identity and the appropriate procedure. The patient was placed

supine on the angiographic table, and the right groin was prepped and draped

in the usual sterile manner. Using a 5 French micropuncture set, the right

common femoral artery was punctured and cannulated, and a 6 French arterial

sheath was placed over a guidewire. The sheath was attached to continuous

heparinized saline flush. A catheter was placed through the sheath and

advanced over a Terumo guidewire into the aortic arch.

Selective catheterization of the following blood vessels was performed (see

below). At the end of the procedure, hemostasis was achieved. Hemostasis was

achieved through placement of a Mynx closure device. Following hemostasis,

with no hematoma, the site was cleaned and dressed with sterile dressing.

Intravenous heparin was intermittently administered throughout the

procedure, monitored with serial ACT measurements, with the ACT maintained

at 250-300. The heparin was not reversed following the procedure.

DIAGNOSTIC ARTERIOGRAPHY AND SUPERVISION AND INTERPRETATION OF DIAGNOSTIC

ARTERIOGRAMS:

LEFT COMMON CAROTID ARTERY: The catheter was used to select the left common

carotid artery. DSA in the AP and lateral views of the cervical region was

performed. The imaged common, internal, and external carotid arteries are

normal in caliber and contour. The carotid bifurcation is widely patent.

LEFT INTERNAL CAROTID ARTERY: The catheter was advanced into the left

internal carotid artery. DSA in the AP, lateral, and oblique views of the

intracranial circulation were performed. The intracranial segments of the

left internal carotid artery are normal in contour and caliber. The middle

cerebral artery and its branch vessels are normal in caliber and contour.

The anterior cerebral artery and its branch vessels are normal in caliber.

There is a saccular aneurysm arising from the left anterior cerebral artery

at the junction of the pericallosal and callosomarginal branches, measuring

3.6 x 3.7 x 4.1 mm, with a 2.9 mm neck, projecting anteriorly, with a small

(1.4 x 1.0 mm) bleb arising from the anterior wall and the anterior internal

frontal branch arising from the aneurysm base. The anterior communicating

artery does not opacify from this injection. Dynamic imaging demonstrates a

normal capillary phase. The intracranial venous structures opacify

appropriately and appear patent.

RIGHT EXTERNAL ILIAC ARTERY: The sheath was withdrawn into the right

external iliac artery. DSA in the RAO and lateral views of the right

iliofemoral arterial system was performed via injection through the sheath.

The imaged iliofemoral arterial system is widely patent. The angiogram

demonstrated conditions amenable to closure device deployment.

SUPERSELECTIVE ARTERIOGRAPHY, EMBOLIZATION, AND FOLLOWUP ANGIOGRAMS;

SUPERVISION AND INTERPRETATION OF SUPERSELECTIVE ARTERIOGRAPHY,

EMBOLIZATION, AND FOLLOWUP ANGIOGRAMS:

EMBOLIZATION: The 6 French guiding catheter was placed into the cervical

left internal carotid artery over a guidewire. A microcatheter was advanced

over a microguidewire into the left anterior cerebral artery aneurysm sac

using roadmap guidance.

Attempts at embolization of the aneurysm were performed. An initial attempt

was made with a Target Soft 4 mm x 8 cm coil, with coil material

consistently and repetitively herniating into the parent vessel. Therefore,

this coil was removed. Subsequently, attempts were made with a Hypersoft 3D

3.5 mm x 5 cm coil and a Target Ultra Soft 3.5 mm x 8 cm coil, with coil

material consistently and repetitively herniating into the parent vessel.

Therefore, these coils were removed. A control angiogram (#1) was done prior

to removal of the last coil, documenting the significant coil herniation

into the parent vessel.

Treatment of the aneurysm was then performed using stent-assisted coil

embolization. A Prowler select plus microcatheter was advanced into the left

anterior cerebral artery over a microguidewire, and an Enterprise 4.5 x 14

mm stent was deployed under continuous fluoroscopic surveillance and roadmap

guidance. A control angiogram (#2) was performed following deployment of the

stent, demonstrating appropriate positioning and wide patency of the stent,

with excellent neck coverage over the aneurysm sac.

Subsequently, an Echelon 10 microcatheter was advanced through the stent

into the left anterior cerebral artery aneurysm sac and coil embolization of

the aneurysm was performed. A total of 7 coils were attempted, and 4 coils

were deployed. Control angiograms (#3-6) were performed intermittently

throughout the embolization procedure to evaluate the results of the

embolization. These control angiograms demonstrate appropriate positioning

of the coil material within the aneurysm sac, with no herniation of coil

material into the parent vessel. There is progressive filling of the

aneurysm sac, with progressively decreasing contrast opacification of the

aneurysm lumen.

The microcatheter was removed and a final control angiogram (#7) in the AP

and lateral views was performed from the guiding catheter with filming over

the intracranial circulation. This imaging sequence demonstrates appropriate

positioning of the coil material within the aneurysm sac, with no herniation

of coil material into the parent artery. The stent remains widely patent and

appropriately positioned. There no significant residual filling of the

aneurysm lumen. No thrombus formation or evidence of distal embolization.

Capillary phase imaging demonstrates normal parenchymal opacification and

arteriovenous transit time. The main intracranial venous structures fill

appropriately.

IMPRESSION:

1. Left anterior cerebral artery aneurysm, measuring 3.6 x 3.7 x 4.1 mm,

with a 2.9 mm neck, projecting anteriorly, with a 1.5 mm bleb arising from

the aneurysm dome.

2. The above-described aneurysm was treated with stent-assisted coil

embolization, resulting in aneurysm occlusion.

PLAN:

1. Aspirin 325 mg daily for life.

2. Plavix 75 mg daily for 6 months.

3. Followup Neurointerventional Surgery Clinic visit in one month.

4. DSA in 6 months.

embolization help--new to me