Endarterectomy and Vascular Revascularization

Alfaro33

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MD coded: 35355, 37221 RT, 37221 LT, 37223 x2, 36200, 36247, 75625, 75710

Myself: 35355, 37221-50, 37223-50, 75625-26

Not too sure about that 50 mod. Any input would help, thank you :)

Operation

1. Right lower extremity ileal femoral endarterectomy with bovine patch angioplasty
2. Diagnostic aortogram with final catheter placement in the abdominal aorta
3. Placement of a left common iliac 8 mm x 59 mm Omnilink balloon expandable stent
4. Placement of a right common iliac 8 mm x 59 mm Omnilink balloon expandable stent
5. Placement of a right external iliac 6 mm x 59 mm Omnilink balloon expandable stent
6. Placement of a right external iliac 6 mm x 60 mm Zilver PTX drug-eluting stent
7. Diagnostic right lower extremity arteriogram with final catheter placement is superficial femoral artery

Findings

Severe aortic iliac occlusive disease
High-grade stenosis along the right and left common iliac arteries
High-grade stenosis through the course of the right external iliac artery
Complete occlusion of the right femoral artery
Widely patent superficial femoral, popliteal, tibioperoneal trunk arteries
Two vessel runoff down to the foot via anterior tibial and posterior tibial arteries

Specimen(s)

Right femoral plaque

Complications

Technique:
Patient was brought into the operative room and intubated in the supine position. Patient was given proper preoperative antibiotics the patient was prepped and draped in usual sterile fashion. Incision was made over the right groin crease and dissection was carried down to the subcutaneous tissue. I encounter the femoral sheath and I carefully dissected the femoral artery. The femoral artery was completely occluded and had marked calcifications through its course. The femoral artery was circumferentially dissected distally and the profunda and SFA bifurcations were skeletonized. Vessel loops were applied to these vessels. Dissection was then carried proximally into the common femoral artery. The plaque extended into the external iliac artery. Therefore to gain further proximal control I had to incise the inguinal ligament. With the inguinal ligament and incised I encounter the crossing femoral genicular vein branches over the femoral artery. These vein branches were ligated with 3 0 Vicryl sutures. The distal external iliac artery had a soft appearing plaque suitable for clamping. Patient was then systemically heparinized.

With all vessels exposed, the patient was then systemically heparinized and I sequentially clamped the SFA profunda and distal external iliac artery. An arteriotomy was created over the femoral artery and Potts scissors were used to extend the arteriotomy proximally and distally. The arteriotomy was extended into the distal external iliac artery. There was dense heavy calcification through the course of the artery and an endarterectomy was then performed with a Freer elevator. Vvessel endarterectomy was performed from the distal external iliac artery down to the SFA. Plaque was lifted and passed off as specimen. The intima over the profunda orifice was tacked with 7 0 Prolene sutures. The intima along the SFA was also tacked posteriorly with 7 0 Prolene sutures. I then introduced a bovine pericardial patch and a perform patch angioplasty along the common femoral artery and distal external iliac artery. With 5 0 Prolene sutures patch angioplasty was then performed in a running fashion. Prior to completion of the patch repair the vessels were flushed in a systemic fashion. The patch was anastomosed and there was a weak pulse along the femoral artery. I than placed a micro puncture needle into the mid femoral artery and a needle was then advanced into the iliac system. This was upsized to a 6 French sheath. Similarly on left common femoral artery a micro needle was placed and micro wire was then advanced into the iliac system. This was upsized to a 6 French sheath as well. On the right access site a Bentson wire was able to manipulate across the lesion into the abdominal aorta. Pigtail catheter was then advanced into the abdominal aorta and selective angiographic run showed that there was high-grade stenosis along both common iliac arteries. On the right there was severe stenosis through the course of the external iliac artery. There was also a high-grade stenosis along the left external iliac artery. Therefore decision was made to place kissing iliac stents to achieve adequate inflow. With Bentson wires crossing both lesions into the abdominal aorta 8 x 59 mm balloon expandable stents were introduced. These were deployed in a kissing fashion just proximal to the aortic bifurcation. Final angiographic run showed excellent resolution of the areas of stenosis. Further angiographic runs in the right lower extremity showed that there was a high-grade stenosis through the course of the external iliac artery more pronounced in the distal portion of external iliac artery. I then introduced a 6 x 60 mm Cook Zilver PTX drug-eluting stent and deployed it on distal external iliac artery. There was intervening area of high-grade stenosis along the proximal external iliac artery and this was bridged with a 6 x 59 mm balloon expandable Omnilink stent. The 6 x 59 mm balloon expandable stent was balloon expanded with an 8 x 40 mm balloon proximally and a 7 x 60 mm balloon through the course of the external iliac artery. Completion angiogram showed excellent resolution of the areas of stenosis and there was an excellent pulse on the right femoral artery. I then removed the sheath and closed arterial puncture site and I placed a micro needle along the distal femoral artery and placed a micro wire into the superficial femoral artery. A micro she has with the placed and diagnostic arteriogram was performed along the right lower extremity which showed a widely patent SFA, popliteal, tibioperoneal trunk. There was essential 2 vessel runoff down to the foot with a dominant vessel being the posterior tibial artery supplying adequate plantar plantar branches.

Satisfied with the patient's circulation, I then removed all wires and catheters and close the arterial puncture site with a 6 0 Prolene suture. The left femoral artery sheath insertion site was closed with a Mynx closure device. Adequate hemostasis was achieved by reversing the heparin followed by fibrillar and vista seal. The right femoral groin was closed in multiple layers and staples were applied. Prevena VAC was then placed over the incision.

This concluded the procedure patient tolerated procedure well was sent to PACU in good condition. Patient is cleared from a vascular surgical standpoint for any future right toe amputations. Patient will need to be on dual anti-platelet therapy with aspirin and Plavix.
 
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