daniel
True Blue
Can I get your take on this, came across your articles online. Very informative.
Would you code both together?
CPT 35256 – Repair blood vessel with vein graft; lower extremity
And
CPT 35903 – Excisioin of infected graft; extremity
Also
Would you use
CPT 75625 – Aortography,abdominal, by serialography
or
CPT 75630 – Aortography, abdominal plus bilateral ilofemoral lower extremity
I’d appreciate your time.
POSTOPERATIVE DIAGNOSIS: Infected open right groin wound,right common iliac artery high-grade stenosis
OPERATION PERFORMED:
(1) Excisional debridement right groin; sharp debridement of skin, subcutaneous tissue, 10 cm x 10 cm
(2) Removal of infected right common to superficial femoral artery bovine pericardial patch
(3) Right greater saphenous vein harvest (length 7 cm)
(4) Right common to superficial femoral artery greater saphenous vein patch angioplasty
(5) Rotational right sartorius muscle flap for coverage of right femoral arteries
(6) Aortogram via right common femoral artery access
(7) Application of wound vac right groin 6 cm x 6 cm
FINDINGS: Necrotic fat right groin, no frank pus, bovine pericardial patch not well incorporated, bovine pericardial patch over common and superficial femoral artery replaced with greater saphenous vein patch. Right greater saphenous vein utilized for vein patch of good quality and 3-4 mm in diameter. Patent profunda femoral artery. Poor back bleeding from superficial femoral artery. Weak right femoral artery pulse. Aortogram indicated high grade stenosis of right common iliac artery, patent but small right external iliac artery, patent right internal iliac artery. Patent left common iliac artery stent, patent external and internal iliac arteries. Because of infected right groin, we did not treat the right common iliac artery access; plan is to place right iliac artery stent via left brachial artery access in a few days. Dopplerable biphasic dorsalis pedis and posterior tibial artery signals at conclusion of procedure.
FLUIDS IN: 4000 cc crystalloid
UOP: 300 cc
EBL: 500 cc
INDICATION: 60 yo alien with history of crack use, hepatitis C, history of splenectomy, s/p previous left iliac artery stent, s/p right common to superficial femoral artery bovine pericardial patch angioplasty January 2017 at an outside facility. The patient has had dehiscence of the right groin wound 3 weeks following the procedure. For the past 6 months, the wound has been open with non healing. She has been doing dressing changes and undergoing debridements at an outside wound clinic. Over the past month, she has had 4 episodes of pulsatile bleeding from the right groin which resolved with compression. CT scan indicates inflammatory changes in the right groin and severe calcification in the right iliac artery. Informed consent was obtained for right groin excisional debridement, removal of bovine pericardial patch and replacement with vein patch, sartorius flap rotation, aortogram with possible right iliac artery stent placement after discussion of the risks and benefits with the patient and her husband.
PROCEDURE: The patient was brought to the operating room and placed supine on the fluoroscopy table. General endotracheal anesthesia was established. Radial arterial line was placed. Foley catheter was placed. Perioperative antibiotics were administered. Abdomen and bilateral lower extremities were prepped and draped in the usual sterile fashion. We extended the original right groin incision superiorly and inferiorly. The subcutaneous tissue was divided with electrocautery. We exposed the inguinal ligament and dissected out the common femoral artery. We partially divided the inguinal ligament and found a soft portion of the distal external iliac artery and it was controlled with vessel loops. We excised the necrotic fat over the open groin wound. Before approaching the patched femoral artery, we dissected out the proximal superficial femoral artery distal to the patch. The greater saphenous vein was seen and exposed at this point and followed to its junction with the common femoral vein. Tributaries were ligated with 3-0 silk sutures. The superficial femoral artery was controlled with vessel loops. We then followed the superficial femoral artery to its origin. The profunda femoris artery was then located. Crossing veins were ligated with 2-0 silk sutures. We placed a vessel loop around the profunda femoris artery. It was a soft vessel. The patch suture line was identified. The patch extended from the common femoral artery and into the first 3 cm of the superficial femoral artery. Large branches off the common femoral artery were controlled with vessel loops. The patient was given 9000 units of heparin. The common femoral, superficial femoral and profunda femoris arteries were clamped. 11 blade was used to create an arteriotomy in the central part of bovine pericardial patch. The patch was removed in its entirety. The artery was trimmed and debrided. The patch was not well incorporated. There was no frank pus. Yasargil was used to control a large posterior branch off the common femoral artery. The common femoral artery was minimally diseased. Approximately 6-7 cm of greater saphenous vein was then harvested. The distal end was ligated with 3-0 silk sutures. The proximal end from the junction was ligated with 2-0 silk stick tie. The vein was of good quality and was 3-4 mm in caliber. It distended well. Finger potts were used to longitudinally transect the vein for the patch. Valves were excised. The vein was sutured over the common femoral and superficial femoral artery with a running 6-0 prolene suture. Prior to completion of the suture line, the femoral arteries were forward and backward bled. There was poor backbleeding from the superficial femoral artery and brisk backbleeding from the profunda femoris artery. There was good but weak inflow. The rest of the suture line was completed. Hemostasis was achieved. We had to place a few repair stitches. There was a decent pulse over the patched artery. He had biphasic posterior tibial and dorsalis pedis signals on the right. We then proceeded to rotate the sartorius muscle over the femoral reconstruction. The lateral border of the sartorius muscle was mobilized. The origin of the sartorius muscle from the anterior superior iliac spine was taken off with electocautery. We mobilized the lateral border of the sartorius muscle to the inferior border of the incision. We also had to mobilize the muscle medially in order to gain enough mobilization. 2 perforators superiorly were divided and ligated. The muscle was of good quality and was viable. The muscle was placed under the femoral nerve bundle. We then proceeded to do an aortogram. Large bore needle was used to access the central portion of the graft. Bentsen wire was navigated into the aorta. 6F sheath was placed. The wire was navigated into the infrarenal aorta with the assistance of a KMP catheter. Pigtail catheter was placed. Aortogram was obtained in multiple views. There was a high-grade lesion of the proximal right common iliac artery. The right internal and external iliac arteries were patent. The external iliac artery was a little large than the 6F sheath. The left common iliac artery stent was patent. The stent originated 2 cm distal to the aortic bifurcation. The left external and iliac arteries were patent. The catheter, wire, and sheath were removed. A figure of eight 6-0 prolene was used to close the access site. Because of the infected right groin wound, we decided it was not prudent to place a stent through this infected area. The right groin wound was copiously irrigated with antibiotic solution. Hemostasis was achieved. The sartorius muscle was secured over the patch with #1 PDS suture to the inguinal ligament and surrounding tissues. There was good coverage. All necrotic tissue and skin was removed. The proximal and distal aspects of the incision was closed with interrupted layers of 2-0 and 3-0 vicryl sutures. 3-0 vertical nylon mattress sutures were used for the skin. We were left with a central open wound measuring 6 x 6 cm. Wound vac was applied. The patient tolerated the procedure well, was extubated, and taken to the recovery room in good condition.
Would you code both together?
CPT 35256 – Repair blood vessel with vein graft; lower extremity
And
CPT 35903 – Excisioin of infected graft; extremity
Also
Would you use
CPT 75625 – Aortography,abdominal, by serialography
or
CPT 75630 – Aortography, abdominal plus bilateral ilofemoral lower extremity
I’d appreciate your time.
POSTOPERATIVE DIAGNOSIS: Infected open right groin wound,right common iliac artery high-grade stenosis
OPERATION PERFORMED:
(1) Excisional debridement right groin; sharp debridement of skin, subcutaneous tissue, 10 cm x 10 cm
(2) Removal of infected right common to superficial femoral artery bovine pericardial patch
(3) Right greater saphenous vein harvest (length 7 cm)
(4) Right common to superficial femoral artery greater saphenous vein patch angioplasty
(5) Rotational right sartorius muscle flap for coverage of right femoral arteries
(6) Aortogram via right common femoral artery access
(7) Application of wound vac right groin 6 cm x 6 cm
FINDINGS: Necrotic fat right groin, no frank pus, bovine pericardial patch not well incorporated, bovine pericardial patch over common and superficial femoral artery replaced with greater saphenous vein patch. Right greater saphenous vein utilized for vein patch of good quality and 3-4 mm in diameter. Patent profunda femoral artery. Poor back bleeding from superficial femoral artery. Weak right femoral artery pulse. Aortogram indicated high grade stenosis of right common iliac artery, patent but small right external iliac artery, patent right internal iliac artery. Patent left common iliac artery stent, patent external and internal iliac arteries. Because of infected right groin, we did not treat the right common iliac artery access; plan is to place right iliac artery stent via left brachial artery access in a few days. Dopplerable biphasic dorsalis pedis and posterior tibial artery signals at conclusion of procedure.
FLUIDS IN: 4000 cc crystalloid
UOP: 300 cc
EBL: 500 cc
INDICATION: 60 yo alien with history of crack use, hepatitis C, history of splenectomy, s/p previous left iliac artery stent, s/p right common to superficial femoral artery bovine pericardial patch angioplasty January 2017 at an outside facility. The patient has had dehiscence of the right groin wound 3 weeks following the procedure. For the past 6 months, the wound has been open with non healing. She has been doing dressing changes and undergoing debridements at an outside wound clinic. Over the past month, she has had 4 episodes of pulsatile bleeding from the right groin which resolved with compression. CT scan indicates inflammatory changes in the right groin and severe calcification in the right iliac artery. Informed consent was obtained for right groin excisional debridement, removal of bovine pericardial patch and replacement with vein patch, sartorius flap rotation, aortogram with possible right iliac artery stent placement after discussion of the risks and benefits with the patient and her husband.
PROCEDURE: The patient was brought to the operating room and placed supine on the fluoroscopy table. General endotracheal anesthesia was established. Radial arterial line was placed. Foley catheter was placed. Perioperative antibiotics were administered. Abdomen and bilateral lower extremities were prepped and draped in the usual sterile fashion. We extended the original right groin incision superiorly and inferiorly. The subcutaneous tissue was divided with electrocautery. We exposed the inguinal ligament and dissected out the common femoral artery. We partially divided the inguinal ligament and found a soft portion of the distal external iliac artery and it was controlled with vessel loops. We excised the necrotic fat over the open groin wound. Before approaching the patched femoral artery, we dissected out the proximal superficial femoral artery distal to the patch. The greater saphenous vein was seen and exposed at this point and followed to its junction with the common femoral vein. Tributaries were ligated with 3-0 silk sutures. The superficial femoral artery was controlled with vessel loops. We then followed the superficial femoral artery to its origin. The profunda femoris artery was then located. Crossing veins were ligated with 2-0 silk sutures. We placed a vessel loop around the profunda femoris artery. It was a soft vessel. The patch suture line was identified. The patch extended from the common femoral artery and into the first 3 cm of the superficial femoral artery. Large branches off the common femoral artery were controlled with vessel loops. The patient was given 9000 units of heparin. The common femoral, superficial femoral and profunda femoris arteries were clamped. 11 blade was used to create an arteriotomy in the central part of bovine pericardial patch. The patch was removed in its entirety. The artery was trimmed and debrided. The patch was not well incorporated. There was no frank pus. Yasargil was used to control a large posterior branch off the common femoral artery. The common femoral artery was minimally diseased. Approximately 6-7 cm of greater saphenous vein was then harvested. The distal end was ligated with 3-0 silk sutures. The proximal end from the junction was ligated with 2-0 silk stick tie. The vein was of good quality and was 3-4 mm in caliber. It distended well. Finger potts were used to longitudinally transect the vein for the patch. Valves were excised. The vein was sutured over the common femoral and superficial femoral artery with a running 6-0 prolene suture. Prior to completion of the suture line, the femoral arteries were forward and backward bled. There was poor backbleeding from the superficial femoral artery and brisk backbleeding from the profunda femoris artery. There was good but weak inflow. The rest of the suture line was completed. Hemostasis was achieved. We had to place a few repair stitches. There was a decent pulse over the patched artery. He had biphasic posterior tibial and dorsalis pedis signals on the right. We then proceeded to rotate the sartorius muscle over the femoral reconstruction. The lateral border of the sartorius muscle was mobilized. The origin of the sartorius muscle from the anterior superior iliac spine was taken off with electocautery. We mobilized the lateral border of the sartorius muscle to the inferior border of the incision. We also had to mobilize the muscle medially in order to gain enough mobilization. 2 perforators superiorly were divided and ligated. The muscle was of good quality and was viable. The muscle was placed under the femoral nerve bundle. We then proceeded to do an aortogram. Large bore needle was used to access the central portion of the graft. Bentsen wire was navigated into the aorta. 6F sheath was placed. The wire was navigated into the infrarenal aorta with the assistance of a KMP catheter. Pigtail catheter was placed. Aortogram was obtained in multiple views. There was a high-grade lesion of the proximal right common iliac artery. The right internal and external iliac arteries were patent. The external iliac artery was a little large than the 6F sheath. The left common iliac artery stent was patent. The stent originated 2 cm distal to the aortic bifurcation. The left external and iliac arteries were patent. The catheter, wire, and sheath were removed. A figure of eight 6-0 prolene was used to close the access site. Because of the infected right groin wound, we decided it was not prudent to place a stent through this infected area. The right groin wound was copiously irrigated with antibiotic solution. Hemostasis was achieved. The sartorius muscle was secured over the patch with #1 PDS suture to the inguinal ligament and surrounding tissues. There was good coverage. All necrotic tissue and skin was removed. The proximal and distal aspects of the incision was closed with interrupted layers of 2-0 and 3-0 vicryl sutures. 3-0 vertical nylon mattress sutures were used for the skin. We were left with a central open wound measuring 6 x 6 cm. Wound vac was applied. The patient tolerated the procedure well, was extubated, and taken to the recovery room in good condition.