jcoder1
Contributor
Can someone please , please help! Cardio is not my expertise and I am not sure what codes to use 36831, 36830, or 36833.. Please read op note
POSTOPERATIVE DIAGNOSIS: Clotted graft, left upper arm.
PROCEDURE: Thrombectomy graft, left upper arm with interposition of a new
graft on the venous end in the left upper arm.
ANESTHESIA: Local with standby sedation.
WHAT WAS DONE: It should be noted that this patient has a clotted graft,
left upper arm for about three weeks. An attempt to open the graft by the
interventional radiologist was not successful, and it was found that the
whole axillary subclavian vein were clotted, even though two weeks prior to
that the patient has a graft in the arm which showed the whole veins were
widely patent. So, I decided to explore the graft and attempt to do
surgical thrombectomy. So, again, with the patient in supine position
under adequate sedation, and the left upper extremity on a side-arm board,
the left upper extremity was prepped and draped in a sterile manner.
Starting near the axilla on the left side, the skin and deep tissue were
infiltrated with a local anesthesia. A longitudinal incision was made.
This incision was carried down carefully. The graft was identified,
dissected out including the venous anastomosis and the native vein proximal
to that. It should be noted that the patient has a stent placed at the
venous end of the graft including the venous anastomosis. So, I had to
dissect the native vein above the venous anastomosis, to be able to place a
vascular clamp. Anyway, at this point, a small transverse incision was
made in the graft just above the venous anastomosis, transecting a portion
of the stent. At this point, an attempt to open the venous anastomosis
itself was not successful, so I decided to explore the vein itself. So as
I mentioned above, already dissected portion of the native vein above the
previous venous anastomosis, I did a longitudinal venotomy and then #3
Fogarty catheter was passed proximally and thrombectomy was done. It
seemed that the vein is widely patent at this level. I was able to pass
without any significant resistance, a #5 dilator and flushed the vein with
a number 12 red rubber catheter without any difficulty. At this time, I
decided to proceed with thrombectomy of the graft itself but using a #4
Fogarty catheter, I was not able to go through the arterial anastomosis.
So at this point, I explored the arterial side of the graft above the elbow
after infiltrating the skin and deep tissue with local anesthesia. An
oblique incision was made. This incision was carried down carefully. The
graft above the arterial anastomosis was identified, dissected out and
isolated between vessel loops. A small transverse incision was made in the
graft and then under vision I was able to identify the arterial plug which
was removed followed by excellent pulsatile flow. The artery was flushed
with heparinized solution. Then, vascular clamp was applied. Then the
graft was flushed both in retrograde and antegrade fashion without any
difficulty and then the incision in the graft on the
arterial end was closed using 6-0 Gore-Tex continuous running suture.
Following that, applying control over the graft near the venous end, I was
able to get a good flow along the graft. So at this point, I decided to
interpose a new 6 mm Gore-Tex graft, to redo the venous anastomosis. So
the graft was totally transected above the venous anastomosis. The
remaining stump was oversewn with 5-0 Prolene continuous running suture.
Then using 6 mm Gore-Tex graft, new end-to-end anastomosis between the 6 mm
Gore-Tex graft and the native vein was done using 6-0 Gore-Tex continuous
running suture, starting one at each end of the anastomosis. After
completing that, all vascular control was removed. There was good backflow
from the vein. It was flushed easily with heparinized solution. Next,
after adjusting the length of the graft, end-to-end anastomosis between the
old and the new graft was done using also 6-0 Gore-Tex continuous running
suture, starting posteriorly and finishing anteriorly. After completing
that, all vascular control was removed. There was good flow and thrill
along the graft. Hemostasis was obtained by applying a piece of Surgicel.
After having adequate hemostasis, the wounds were closed in one layer,
using 4-0 Prolene interrupted simple mattress stitches. Sterile dressing
was applied. Procedure was well tolerated by the patient. The patient
left to recovery in satisfactory condition.
POSTOPERATIVE DIAGNOSIS: Clotted graft, left upper arm.
PROCEDURE: Thrombectomy graft, left upper arm with interposition of a new
graft on the venous end in the left upper arm.
ANESTHESIA: Local with standby sedation.
WHAT WAS DONE: It should be noted that this patient has a clotted graft,
left upper arm for about three weeks. An attempt to open the graft by the
interventional radiologist was not successful, and it was found that the
whole axillary subclavian vein were clotted, even though two weeks prior to
that the patient has a graft in the arm which showed the whole veins were
widely patent. So, I decided to explore the graft and attempt to do
surgical thrombectomy. So, again, with the patient in supine position
under adequate sedation, and the left upper extremity on a side-arm board,
the left upper extremity was prepped and draped in a sterile manner.
Starting near the axilla on the left side, the skin and deep tissue were
infiltrated with a local anesthesia. A longitudinal incision was made.
This incision was carried down carefully. The graft was identified,
dissected out including the venous anastomosis and the native vein proximal
to that. It should be noted that the patient has a stent placed at the
venous end of the graft including the venous anastomosis. So, I had to
dissect the native vein above the venous anastomosis, to be able to place a
vascular clamp. Anyway, at this point, a small transverse incision was
made in the graft just above the venous anastomosis, transecting a portion
of the stent. At this point, an attempt to open the venous anastomosis
itself was not successful, so I decided to explore the vein itself. So as
I mentioned above, already dissected portion of the native vein above the
previous venous anastomosis, I did a longitudinal venotomy and then #3
Fogarty catheter was passed proximally and thrombectomy was done. It
seemed that the vein is widely patent at this level. I was able to pass
without any significant resistance, a #5 dilator and flushed the vein with
a number 12 red rubber catheter without any difficulty. At this time, I
decided to proceed with thrombectomy of the graft itself but using a #4
Fogarty catheter, I was not able to go through the arterial anastomosis.
So at this point, I explored the arterial side of the graft above the elbow
after infiltrating the skin and deep tissue with local anesthesia. An
oblique incision was made. This incision was carried down carefully. The
graft above the arterial anastomosis was identified, dissected out and
isolated between vessel loops. A small transverse incision was made in the
graft and then under vision I was able to identify the arterial plug which
was removed followed by excellent pulsatile flow. The artery was flushed
with heparinized solution. Then, vascular clamp was applied. Then the
graft was flushed both in retrograde and antegrade fashion without any
difficulty and then the incision in the graft on the
arterial end was closed using 6-0 Gore-Tex continuous running suture.
Following that, applying control over the graft near the venous end, I was
able to get a good flow along the graft. So at this point, I decided to
interpose a new 6 mm Gore-Tex graft, to redo the venous anastomosis. So
the graft was totally transected above the venous anastomosis. The
remaining stump was oversewn with 5-0 Prolene continuous running suture.
Then using 6 mm Gore-Tex graft, new end-to-end anastomosis between the 6 mm
Gore-Tex graft and the native vein was done using 6-0 Gore-Tex continuous
running suture, starting one at each end of the anastomosis. After
completing that, all vascular control was removed. There was good backflow
from the vein. It was flushed easily with heparinized solution. Next,
after adjusting the length of the graft, end-to-end anastomosis between the
old and the new graft was done using also 6-0 Gore-Tex continuous running
suture, starting posteriorly and finishing anteriorly. After completing
that, all vascular control was removed. There was good flow and thrill
along the graft. Hemostasis was obtained by applying a piece of Surgicel.
After having adequate hemostasis, the wounds were closed in one layer,
using 4-0 Prolene interrupted simple mattress stitches. Sterile dressing
was applied. Procedure was well tolerated by the patient. The patient
left to recovery in satisfactory condition.