Axillary artery to atrial bypass


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Any thoughts on how to code the procedure below? Thanks :)

PREOPERATIVE DIAGNOSIS: Right subclavian vein thrombosis, status post first
rib resection, status post stenting of the right subclavian vein.

1. Right axillary vein to the right atrial bypass using a bilateral saphenous
vein spiral graft. 2. Explantation of 2 covered stents from the right axillary
vein and subclavian vein.

POSTOPERATIVE DIAGNOSIS: Right subclavian vein thrombosis, status post first
rib resection, status post stenting of the right subclavian vein.

CLINICAL NOTE: This is a young male with the multiple interventions for
right axillary and subclavian vein thromboses. I had been following him for
many months, and despite evidence of collateralization, he still feels that
he is incapacitated, having venous hypertension and discomfort with use of
the right arm. After multiple discussions with and his family, we
decided to proceed with a bypass knowing that it will take some time to
determine if this bypass will be beneficial with regard to his symptoms. He
had satisfactory saphenous vein. We were able to create a satisfactory
bypass. He did have a bleeding venous collateral just superior to the
collarbone which required a counterincision for control, but once this was
controlled, the hemostasis was completely achieved, and he was taken the ICU
in stable condition.

OPERATIVE NOTE: Once the patient was brought to the operating suite, he was
prepped and draped in the usual sterile fashion. Bilateral endoscopic vein
harvesting was performed, and a spiral graft was created over a 36-French
chest tube using 5-0 Prolene suture. Then, the right axilla was opened, and
a soft non scarred axillary vein was identified with multiple collaterals
contributing to this vein. We then performed a sternotomy. We then were
able to isolate the innominate vein and the superior vena cava, opened an
occluded subclavian vein on the right, and explanted 2 covered stents from
this area. We then closed the venotomy and restored the innominate and SVC
flow. The patient tolerated this maneuver well. Then we created a tract
between the collarbone and the remnant of the first rib scar to the axilla.
We did incur a venous bleeder here which I felt would stop, but ultimately
later required a counterincision above the clavicle for control. We then
anastomosed the spiral vein graft to the confluence of the axillary artery
and several tributaries and then tunneled this into the chest. We then
performed a vein to right atrial anastomosis using 5-0 Prolene, and then flow
was restored to the system. Protamine was administered. There continued to
be oozing from the venous collateral underneath the collarbone, and thus we
made the counterincision, identified this, and oversew it with 4-0 Prolene
suture. Then, once hemostasis had been achieved, all wounds were irrigated
and closed in several layers. At this point, he was stable and was
transferred to Cardiothoracic ICU.

ATTESTATION STATEMENT: I was present for the entire duration of this