ellis3350
Guru
Hello,
I was going to ask this question on Dr. Z but I feel it may go over the allowed word count. Any help would be appreciated.
Indication
Patient is a 69-year-old man with multiple prior vascular procedures including a femoral endarterectomy with bovine pericardial patch angioplasty approximately 1 month ago. He presented during this admission with a severe wound infection of the right groin. This was opened and debrided with infection extending down to the femoral artery. He later underwent a right sartorius flap. Approximately 24 hours ago the patient developed brisk bleeding from the right groin. At that time we explored the groin and temporarily repaired the site of bleeding with plans to perform a definitive repair within the next 48 hours. This morning, the patient developed recurrent bleeding at his right femoral artery. We plan for definitive repair.
Findings
Right femoral artery, including patch angioplasty, resected. Reconstruction performed with cryopreserved artery from the external iliac to the bypass in an end-to-end fashion with a jump graft to the profunda.
This case was substantially more difficult than usual because of significant effort and difficulty mobilizing and identifying anatomical structures due to altered surgical field secondary to previous surgery, infection and inflammation.
Operative Note Narrative
The patient was taken directly from the ICU to the operating room intubated. He was placed on the operating room table in the supine position. He was prepped from his abdomen to bilateral feet and draped in the usual sterile fashion. A time-out was performed verifying correct patient, procedure, positioning, and postoperative destination. We began the procedure by performing an ultrasound of the left common femoral artery. This was found to be patent. Under direct ultrasound visualization, the left common femoral artery was accessed with a micropuncture needle and a micropuncture wire was advanced into the iliac vessel without difficulty. Imaging of the real-time ultrasound-guided access showing needle entry into the common femoral artery were saved in the patient's permanent medical record for documentation. Fluoroscopy was used to confirm the appropriate level of the arterial puncture of the femoral head. A micropuncture sheath was then inserted and exchanged to a 4 French sheath over a Bentson wire. An Omni Flush catheter was then used to select the right common iliac artery. Wire and catheter were advanced into the right external iliac artery. We exchanged our wire for an Amplatz wire and then upsized our sheath to a 6 French 45 cm sheath. The patient was heparinized at this point the serial monitoring of the ACT throughout the remainder of the case to ensure an ACT greater than 250 seconds. We then placed a 8 x 40 mm balloon into the right external iliac artery to use as proximal control prior to exploring the right common femoral artery. The balloon was inflated. This point we turned our attention to exposing the right femoral artery. The sartorius flap sutures were divided and the muscle flap was rotated laterally. There is no apparent gross bleeding from the patch at this time with our balloon inflated. We turned our attention to gaining proximal control of the external iliac artery. There was dense scar tissue overlying the proximal common femoral artery at the level of the inguinal ligament. A tedious dissection ensued but eventually we were able to gain circumferential control of the external iliac artery. At this point we deflated our balloon in the external iliac artery. There was no apparent bleeding from the patch at this time so we continued our dissection with a clamp around the external iliac artery but not tightened down. We mobilized the very scarred common femoral artery and patch on its medial and lateral aspects. We then turned our attention to identifying the patient's bypass. His groin incision was extended distally and we gained circumferential control of the bypass. Finally, we identified the patient's profunda. In order to do so we opened the patch and used a 3 Fogarty balloon to occlude the origin of the profundus. From here we were able to identify the location of the vessel more definitively. Circumferential control was gained of the main lateral profunda branch which was the only patent branch. We then selected a cryopreserved femoral popliteal segment which measured between 6-7 mm in diameter. We resected the common femoral artery from the level of the external iliac to the 1st cm of the patient's bypass. The proximal aspect of the bypass was sent for stat Gram stain to ensure no infection at this location. This came back as no organisms identified. We then performed an end-to-end anastomosis using our cryo preserved artery between the external iliac artery and the patient's prior femoral to popliteal bypass. We then performed a jump graft from the side of this interposition to the origin of the profunda. Prior to completing our suture lines, the grafts were forward and back bled appropriately. We then used a Doppler to listen the signals within the graft and the profundus and these were excellent. The patient had dopplerable pedal signals. We then performed a right lower extremity angiogram via the sheath in the external iliac artery. This demonstrated a patent reconstructed common femoral artery with excellent flow into the lateral profunda branches. The patient's bypass graft was patent. He had patent tibial flow to the foot. We removed the left femoral sheath and used a Perclose to close the arteriotomy. Manual pressure was held over the arteriotomy until hemostasis was confirmed. Protamine was given for reversal. We confirmed hemostasis throughout the surgical field. Our plastic surgery colleagues then entered the operating room to evaluate the sartorius flap. The debrided a segment of the flap and recent cured it along its prior location. A surgical drain was placed into the sartorius flap harvest site and secured at the skin with a nylon stitch. We then proceeded to close the deep layers of the rest of the groin incision using 2-0 followed by 3-0 Vicryl suture. Nylon sutures were used at the skin proximally and distally. The midportion of the wound was left open with the sartorius flap underneath. A wound VAC was placed over this remaining open portion of the skin incision. The procedure was then concluded. At the end of the procedure, all sponge, needle, and instrument counts were reported as correct x2. The patient was then transferred to the ICU intubated and in stable condition.
I was thinking 35860,22,78,RT but then part of me wants to code this as 35286,22,78,RT or maybe both codes.
I was going to ask this question on Dr. Z but I feel it may go over the allowed word count. Any help would be appreciated.
Indication
Patient is a 69-year-old man with multiple prior vascular procedures including a femoral endarterectomy with bovine pericardial patch angioplasty approximately 1 month ago. He presented during this admission with a severe wound infection of the right groin. This was opened and debrided with infection extending down to the femoral artery. He later underwent a right sartorius flap. Approximately 24 hours ago the patient developed brisk bleeding from the right groin. At that time we explored the groin and temporarily repaired the site of bleeding with plans to perform a definitive repair within the next 48 hours. This morning, the patient developed recurrent bleeding at his right femoral artery. We plan for definitive repair.
Findings
Right femoral artery, including patch angioplasty, resected. Reconstruction performed with cryopreserved artery from the external iliac to the bypass in an end-to-end fashion with a jump graft to the profunda.
This case was substantially more difficult than usual because of significant effort and difficulty mobilizing and identifying anatomical structures due to altered surgical field secondary to previous surgery, infection and inflammation.
Operative Note Narrative
The patient was taken directly from the ICU to the operating room intubated. He was placed on the operating room table in the supine position. He was prepped from his abdomen to bilateral feet and draped in the usual sterile fashion. A time-out was performed verifying correct patient, procedure, positioning, and postoperative destination. We began the procedure by performing an ultrasound of the left common femoral artery. This was found to be patent. Under direct ultrasound visualization, the left common femoral artery was accessed with a micropuncture needle and a micropuncture wire was advanced into the iliac vessel without difficulty. Imaging of the real-time ultrasound-guided access showing needle entry into the common femoral artery were saved in the patient's permanent medical record for documentation. Fluoroscopy was used to confirm the appropriate level of the arterial puncture of the femoral head. A micropuncture sheath was then inserted and exchanged to a 4 French sheath over a Bentson wire. An Omni Flush catheter was then used to select the right common iliac artery. Wire and catheter were advanced into the right external iliac artery. We exchanged our wire for an Amplatz wire and then upsized our sheath to a 6 French 45 cm sheath. The patient was heparinized at this point the serial monitoring of the ACT throughout the remainder of the case to ensure an ACT greater than 250 seconds. We then placed a 8 x 40 mm balloon into the right external iliac artery to use as proximal control prior to exploring the right common femoral artery. The balloon was inflated. This point we turned our attention to exposing the right femoral artery. The sartorius flap sutures were divided and the muscle flap was rotated laterally. There is no apparent gross bleeding from the patch at this time with our balloon inflated. We turned our attention to gaining proximal control of the external iliac artery. There was dense scar tissue overlying the proximal common femoral artery at the level of the inguinal ligament. A tedious dissection ensued but eventually we were able to gain circumferential control of the external iliac artery. At this point we deflated our balloon in the external iliac artery. There was no apparent bleeding from the patch at this time so we continued our dissection with a clamp around the external iliac artery but not tightened down. We mobilized the very scarred common femoral artery and patch on its medial and lateral aspects. We then turned our attention to identifying the patient's bypass. His groin incision was extended distally and we gained circumferential control of the bypass. Finally, we identified the patient's profunda. In order to do so we opened the patch and used a 3 Fogarty balloon to occlude the origin of the profundus. From here we were able to identify the location of the vessel more definitively. Circumferential control was gained of the main lateral profunda branch which was the only patent branch. We then selected a cryopreserved femoral popliteal segment which measured between 6-7 mm in diameter. We resected the common femoral artery from the level of the external iliac to the 1st cm of the patient's bypass. The proximal aspect of the bypass was sent for stat Gram stain to ensure no infection at this location. This came back as no organisms identified. We then performed an end-to-end anastomosis using our cryo preserved artery between the external iliac artery and the patient's prior femoral to popliteal bypass. We then performed a jump graft from the side of this interposition to the origin of the profunda. Prior to completing our suture lines, the grafts were forward and back bled appropriately. We then used a Doppler to listen the signals within the graft and the profundus and these were excellent. The patient had dopplerable pedal signals. We then performed a right lower extremity angiogram via the sheath in the external iliac artery. This demonstrated a patent reconstructed common femoral artery with excellent flow into the lateral profunda branches. The patient's bypass graft was patent. He had patent tibial flow to the foot. We removed the left femoral sheath and used a Perclose to close the arteriotomy. Manual pressure was held over the arteriotomy until hemostasis was confirmed. Protamine was given for reversal. We confirmed hemostasis throughout the surgical field. Our plastic surgery colleagues then entered the operating room to evaluate the sartorius flap. The debrided a segment of the flap and recent cured it along its prior location. A surgical drain was placed into the sartorius flap harvest site and secured at the skin with a nylon stitch. We then proceeded to close the deep layers of the rest of the groin incision using 2-0 followed by 3-0 Vicryl suture. Nylon sutures were used at the skin proximally and distally. The midportion of the wound was left open with the sartorius flap underneath. A wound VAC was placed over this remaining open portion of the skin incision. The procedure was then concluded. At the end of the procedure, all sponge, needle, and instrument counts were reported as correct x2. The patient was then transferred to the ICU intubated and in stable condition.
I was thinking 35860,22,78,RT but then part of me wants to code this as 35286,22,78,RT or maybe both codes.