Portal Vein Embolization coding sample report

Portal Vein Embolization coding sample reportPROCEDURE: EXTENDED RIGHT PORTAL VEIN EMBOLIZATION

INDICATIONS: History of sigmoid colon cancer with liver metastasis. Approximately 10 lesions are identified on intraoperative ultrasound within segments four through eight. The patient is a candidate for hepatic trisegmentectomy however, the FLR is diminutive at approximately 12%. Extended right portal vein embolization is being performed to create hypertrophy of his future liver remnant and allow resection.

MEDICATIONS: General anesthesia. 1 gram Ancef at scheduled intervals administered by anesthesia.



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PROCEDURE: Written informed consent was obtained in a SPARQ conference with the patient. The patient was prepped and draped in the usual manner. Utilizing ultrasound guidance, access was gained to a small peripheral portal vein branch of segment six utilizing a 21 gauge needle. A 6-French sheath was advanced into the main portal vein. A 5-French pigtail catheter was then advanced over the wire into the main portal vein in a diagnostic portogram was performed in the AP and RAO imaging planes. A main portal vein pressure measurement was obtained. Subsequently, the left main portal vein was selectively catheterized followed by subtraction portography in multiple obliquities. A coned beam 3-D CT was also performed within the left portal vein for delineation of this patient's segment 4 portal venous anatomy. Subsequently, segment four branches were catheterized and embolization was performed utilizing a 100 - 300 micron and 300 - 500 micron bead block. Additional coil embolization was performed utilizing multiple 3 and 4 mm coils. A single 4-mm Nester coil was noted to partially prolapsing into midportion of the left main portal vein. Multiple imaging of obliquities were performed in an effort to document positioning within the portal vein. A decision was made to not retrieve this coil due to technical challenges. After completion of segment four branch embolization, attention was turned to the segments five through eight. Selective catheterization of dominant right portal vein branches was then performed followed by embolization utilizing 100 - 300 and 300 - 500 micron bead block and embospheres. Additional coil embolization was performed utilizing multiple 4, 6, 8, 10 and 14 mm coils. Completion portography was then performed documenting complete occlusion of right portal vein and segment four branches. The percutaneous tract was then embolized utilizing three 4 mm coils. Hemostasis was immediate.

FINDINGS: Ultrasound imaging demonstrates identification of a segment six branch of the right portal vein. Real time imaging demonstrates realization of a 21 gauge needle within the peripheral segmental branch to allow portal venous access. Diagnostic portography demonstrates a patent main, right and left portal vein. Selective left portal vein imaging demonstrates multiple branches arising off of the left portal vein supplying segment four. Cone beam 3-D CT imaging further confirms the presence of five branches arising off of the left portal vein supplying segment four. Initial portography following embolization of segment four demonstrates some pruning of peripheral vasculature within the lateral segment of segment four. This finding is felt to be secondary to portal - portal collateral intrahepatic shunting. Following embolization of the six main branches of the right main portal vein completion portography demonstrates no residual flow within the right main portal vein or segment four branches. Improved flow is identified within the left main portal vein supplying the lateral segments and the caudate lobe.

Portal pressure measurements:

Pre-embolization: 16/14 mmHg. Mean 15 mmHg.

Post-embolization: 19/17 mmHg. Mean 18 mmHg.

IMPRESSION: 1. Technically successful extended right hepatic portal vein embolization as detailed above. There is partial displacement of a single segment four coiled into the left main portal vein which is non flow limiting.

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