sslater
Networker
Need help with coding this... am not familiar with AAA procedure. Would appreciate any help with this. Thank u in advance!! 
PREOPERATIVE DIAGNOSIS:
Distal aortic suture line pseudoaneurysm and two right iliac
aneurysms.
POSTOPERATIVE DIAGNOSIS:
Distal aortic suture line pseudoaneurysm and two right iliac
aneurysms.
OPERATIVE PROCEDURE:
1. Abdominal aortic stent graft.
2. Embolization of right internal iliac artery.
PROCEDURE: The patient was brought in the operating room and
placed in the supine position and underwent induction of general
endotracheal anesthesia. He was then positioned, prepped, and
draped in the usual sterile fashion.
Initial step was to place an 8-French sheath in the left groin,
which was done percutaneously. Once this was in place transverse
incision was made over the right groin and the common femoral
artery exposed for adequate length.
Initial step here was to embolize the right internal iliac
artery. Initially we tried this by placing a 6-French sheath in
the right femoral artery and accessing the internal iliac with
various sorts of hook-type guiding catheters. We were
unsuccessful in this after an extended period of time. Next we
went to the left groin, crossed the iliac bifurcation using a
contra catheter and glidewires. We were able to get a guidewire
into the internal iliac and extend the guiding cath in but were
never able to extend the sheath into that area. After an
extended period of time doing this, Dr. X graciously came in
and helped us address this problem. He was able to get a guiding
catheter over to the 8-French x 55 sheath at the left groin over
the bifurcation and once this was in place then cannulate the
internal iliac with an 0.014 coronary wire over which we were
able to eventually advance the sheath and get good purchase into
the internal iliac artery.
Once we had done this two Amplatz occluder devices, first an 8 mm
and then once this was deployed per routine a second 6-mm Amplatz
occluder device was deployed. Once this was done initial
angiogram showed continued flow into the internal iliac artery
but good position of the Amplatz devices.
Once we had gotten this done, which actually took a number of
hours, we proceeded on with the aneurysm repair. The short 8-
French sheath was replaced in the left groin. A 12-French strip-
away sheath was placed in the right groin. Once these were in
place a Meier wire was advanced up the right iliac into the
thoracic aorta. The Endologix device was then advanced up over
the wire into the thoracic aorta loaded with a 28 x 16 __________
bifurcator device. Just prior to placing this, the SurePass
guidewire to the contra lateral limb was advanced up the sheath
grabbed with a snare and brought out the left 8-French sheath.
Once we had done this we were able to strip away the strip-away
sheath in the right groin advancing the entire device up into the
thoracic aorta as noted above. Once this was in position the
wires were in the sheath and the device was appropriately
oriented and wires under nice control, we were able to retract
the stent graft integrating sheath below the iliac bifurcation.
Once we had done this we were able to pull the entire system down
to the aortic bifurcation seating it nicely by the aortic
bifurcation. An 0.014 Endologix wire was then advanced up the
SurePass contra limb precannulating gate before deployed. Once
we had done this we deployed the main body of the graft by
pulling the device control cord. Having done this we were able
to retract the integrated sheath deploy the ipsilateral limb.
Having successfully deployed both limbs a pigtail catheter was
advanced up the 0.014 left groin 0.014 wire and aortogram
performed. Note the location of the renal arteries were noted at
this point in time. Having done this we placed the infrarenal 34-
34-100 aortic extension using the pin and pull technique and
placed it just at the top of the previously placed graft
specifically below the area of about 50% narrowing in the main
aorta. Once this was successfully deployed the main body overlap
and proximal areas were dilated with a Reliant balloon and the
right limb of the graft dilated as well.
At this point in time we advanced an 0.014 guidewire back up the
pigtail catheter, pulled it back to the aortic bifurcation then
carefully advancing it up using a little twirl as went. We
advanced the pigtail back up to the aorta just above the upper
limits of the graft. Having done this we were able to go ahead
over the right limb guidewire advance a 20 x 13 x 70 right limb
extension. We positioned this and successfully deployed this.
Having done this, Coda balloon was used to dilate this as well.
Following this a completion arteriogram was shot. We showed no
evidence of any endoleak. The proximal location was perfect. By
this time the right internal iliac was totally occluded as per
our plans with good flow into the right iliac artery. We felt at
this point we did not need to dilate the left limb as there was
good apposition and good flow.
Having done all this we were able to go ahead and remove all the
devices from the right femoral artery. Clamps were applied and
the artery carefully reapproximated using 6-0 Prolene. This was
a heavily diseased artery and actually we noted we did have
virtually no back flow. However once we got the artery repaired,
released the clamp to good pulse and good Doppler pulse from the
left ankle and so we felt we were okay.
Having done this ACT was done and was found to be adequate. The
right groin was closed using running 3-0 Vicryl deep and running
subcuticular 4-0 Vicryl on the skin. The left 8-French sheath
was removed and we used a Mynx closure device for this procedure.
This worked well and successfully.
PREOPERATIVE DIAGNOSIS:
Distal aortic suture line pseudoaneurysm and two right iliac
aneurysms.
POSTOPERATIVE DIAGNOSIS:
Distal aortic suture line pseudoaneurysm and two right iliac
aneurysms.
OPERATIVE PROCEDURE:
1. Abdominal aortic stent graft.
2. Embolization of right internal iliac artery.
PROCEDURE: The patient was brought in the operating room and
placed in the supine position and underwent induction of general
endotracheal anesthesia. He was then positioned, prepped, and
draped in the usual sterile fashion.
Initial step was to place an 8-French sheath in the left groin,
which was done percutaneously. Once this was in place transverse
incision was made over the right groin and the common femoral
artery exposed for adequate length.
Initial step here was to embolize the right internal iliac
artery. Initially we tried this by placing a 6-French sheath in
the right femoral artery and accessing the internal iliac with
various sorts of hook-type guiding catheters. We were
unsuccessful in this after an extended period of time. Next we
went to the left groin, crossed the iliac bifurcation using a
contra catheter and glidewires. We were able to get a guidewire
into the internal iliac and extend the guiding cath in but were
never able to extend the sheath into that area. After an
extended period of time doing this, Dr. X graciously came in
and helped us address this problem. He was able to get a guiding
catheter over to the 8-French x 55 sheath at the left groin over
the bifurcation and once this was in place then cannulate the
internal iliac with an 0.014 coronary wire over which we were
able to eventually advance the sheath and get good purchase into
the internal iliac artery.
Once we had done this two Amplatz occluder devices, first an 8 mm
and then once this was deployed per routine a second 6-mm Amplatz
occluder device was deployed. Once this was done initial
angiogram showed continued flow into the internal iliac artery
but good position of the Amplatz devices.
Once we had gotten this done, which actually took a number of
hours, we proceeded on with the aneurysm repair. The short 8-
French sheath was replaced in the left groin. A 12-French strip-
away sheath was placed in the right groin. Once these were in
place a Meier wire was advanced up the right iliac into the
thoracic aorta. The Endologix device was then advanced up over
the wire into the thoracic aorta loaded with a 28 x 16 __________
bifurcator device. Just prior to placing this, the SurePass
guidewire to the contra lateral limb was advanced up the sheath
grabbed with a snare and brought out the left 8-French sheath.
Once we had done this we were able to strip away the strip-away
sheath in the right groin advancing the entire device up into the
thoracic aorta as noted above. Once this was in position the
wires were in the sheath and the device was appropriately
oriented and wires under nice control, we were able to retract
the stent graft integrating sheath below the iliac bifurcation.
Once we had done this we were able to pull the entire system down
to the aortic bifurcation seating it nicely by the aortic
bifurcation. An 0.014 Endologix wire was then advanced up the
SurePass contra limb precannulating gate before deployed. Once
we had done this we deployed the main body of the graft by
pulling the device control cord. Having done this we were able
to retract the integrated sheath deploy the ipsilateral limb.
Having successfully deployed both limbs a pigtail catheter was
advanced up the 0.014 left groin 0.014 wire and aortogram
performed. Note the location of the renal arteries were noted at
this point in time. Having done this we placed the infrarenal 34-
34-100 aortic extension using the pin and pull technique and
placed it just at the top of the previously placed graft
specifically below the area of about 50% narrowing in the main
aorta. Once this was successfully deployed the main body overlap
and proximal areas were dilated with a Reliant balloon and the
right limb of the graft dilated as well.
At this point in time we advanced an 0.014 guidewire back up the
pigtail catheter, pulled it back to the aortic bifurcation then
carefully advancing it up using a little twirl as went. We
advanced the pigtail back up to the aorta just above the upper
limits of the graft. Having done this we were able to go ahead
over the right limb guidewire advance a 20 x 13 x 70 right limb
extension. We positioned this and successfully deployed this.
Having done this, Coda balloon was used to dilate this as well.
Following this a completion arteriogram was shot. We showed no
evidence of any endoleak. The proximal location was perfect. By
this time the right internal iliac was totally occluded as per
our plans with good flow into the right iliac artery. We felt at
this point we did not need to dilate the left limb as there was
good apposition and good flow.
Having done all this we were able to go ahead and remove all the
devices from the right femoral artery. Clamps were applied and
the artery carefully reapproximated using 6-0 Prolene. This was
a heavily diseased artery and actually we noted we did have
virtually no back flow. However once we got the artery repaired,
released the clamp to good pulse and good Doppler pulse from the
left ankle and so we felt we were okay.
Having done this ACT was done and was found to be adequate. The
right groin was closed using running 3-0 Vicryl deep and running
subcuticular 4-0 Vicryl on the skin. The left 8-French sheath
was removed and we used a Mynx closure device for this procedure.
This worked well and successfully.