Performance Measurement Network

Question: Failed Attempt at Thrombectomy

Additional case for Review.

Is it correct to abstract "yes" to failed thrombectomy for the following case?

Preprocedure H&P: IMPRESSION Acute left vertebral occlusion with lateral medullary syndrome Recent STEMI RECOMMENDATIONS I discussed medical management with the patient vs. Thrombectomy given that the basilar artery is open and there would be risk to basilar embolization. This was specifically discussed. Given that his symptoms are worsening and he is having secretion issues, he would like to undergo thrombectomy.

Procedure note: Procedure: Cerebral angiogram 4/17/2019.

Indication: The patient is a 56 year old male who presents with worsening left ataxia, dysarthria, and dysphagia. CTA showing pre-PICA left vertebral occlusion Imaging: CTA inadequate for degree of stenosis

Preop Diagnosis: left PICA stroke Post op Diagnosis: Same Medications: 3000 units Heparin IV, 0.5 mg Versed, 25 mg Fentanyl

Procedural Detail: The risks, benefits, and alternatives to the procedure were discussed in detail with the patient. He indicated understanding and wished to proceed. The patient was brought to the biplane angiography suite where he underwent routine prep and drape procedures. A 6F sheath was placed in the rt femoral artery and a 5F, Angled glide catheter was used for vessel selection. Multiple images and projections were obtained. At the conclusion a femoral artery angiogram was obtained through the sheath and hemostasis was achieved using a Proglide closure device. The patient tolerated the procedure without immediate complications. He was returned to the recovery area in hemodynamically stable condition and neurologically unchanged. Estimated blood loss: negligible Fluoroscopic Time: 24.8 min

Diagnostic Cerebral Angiogram:

The right subclavian artery was selected and a runoff performed demonstrated an extremely tortuous vertebral with otherwise normal vertebral ostium and its proximal segments. The right vertebral artery was selected and intracranial runs demonstrate a normal distal course of the vertebral, basilar and bilateral posterior cerebral arteries. There is a high grade stenosis of the V4 segment just proximal to the VB junction. The left subclavian artery was selected and a runoff performed demonstrated an extremely tortuous vertebral with otherwise normal vertebral ostium and its proximal segments. The left vertebral artery was selected and intracranial runs demonstrate a complete occlusion of the vertebral artery. Following administration of heparin the pre-PICA segment opened allowing complete PICA flow. The V4 segment remained occluded. The sheath was switch out over an exchange bentson for a 7fr. 80 cm shuttle. The left vertebral artery was selected using the ACE 64 and velocity microcatheter. A Synchro 2 soft was initially used for navigation, however this was later switched to the synchro standard. Multiple microcatheter runs were made from the distal left vertebral artery to delineate the residual occlusion. The clot in the distal vertebral artery was encountered. It was very well organized and had been there for a long time. It was so solid the microcatheter and microwire could not safely pass through it. To avoid risk of disruption of the organized clot and potential for dissection and/or vessel ruptured. The Procedure was concluded without performing any thrombectomy. A run performed of the bifurcation of the common iliac arteries from the common femoral artery sheath demonstrated a normal common femoral artery bifurcation with no dissection or filling defect. The sheath was exchanged for the Proglide closure device. The device was deployed and hemostasis was achieved. Impression: Recanalization of PICA following heparin administration V4 segment distal to PICA remains occluded.



Jennifer, This forum is offered as assistance for Joint Commission certified customers collecting and submitting performance measure data to The Joint Commission. It is not the intent for Joint Commission staff to do the abstraction.

Many of your cases have been reviewed and guidance provided. Go with your judgement. We've agreed for the most part.

Thank you.

P.S. Select "Yes" . The procedure was concluded without performing any thrombectomy. V4 segment remains occluded.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-08, CSTK-11, CSTK-12, Failed Attempt at Thrombectomy,
Manual: Current Manual (current data collection period; prior to data transmission)

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