Jane5711
Networker
Hi,
Need help with an EVAR -- The codes I'm thinking of are 34705-62 and 34713-50-59. Not sure whether to use 34709 for limb extensions. Any help would be appreciated.
TIA
Procedure:
PERCUTANEOUS ENDOVASCULAR REPAIR OF INFRARENAL AAA, WITH A 23MM BIFURCATING ALTO ENDOGRAFT, VIA RIGHT FEMORAL ARTERY, AND 18 X 12CM OVATION iX LIMB INSERTION VIA RIGHT FEMORAL ARTERY, AND 28 X 12CM OVATION iX LIMB INSERTION VIA LEFT FEMORAL ARTERY
PROCEDURE DESCRIPTION:
After obtaining informed written patient's consent, patient was brought to the hybrid OR suite, and situated on the table. Anesthesia was administered by department of anesthesia, please see separate report. Appropriate timeout was called.
Initial arterial access was obtained to the right femoral artery with ultrasound guidance, and modified Seldinger technique, using micropuncture kit, and 2 Perclose catheters were used for preclosure of the right femoral artery at 10:00, and 2:00, 8 French sheath was introduced. The same technique access to the left femoral artery was obtained, and 2 Perclose catheters were used for preclosure of the left femoral artery, 8 French sheath was introduced.
Patient was heparinized, for ACT more than 250.
Once double access was obtained, we placed 300 cm supra core wire, and then exchanged it over the JR4 catheter to the 300 cm Lunderquist wire from the right femoral access, and from the left femoral artery, a 5 French pigtail measuring catheter was positioned to the abdominal aorta above the origin of renal arteries, and abdominal aortogram was obtained in 5 degree cranial and 30 degree LAO view with power injection of 15 cc of contrast. The origin of the renal arteries was well visualized, and respectively marked. Overall aortic and iliac artery anatomy was reexamined.
The introducer sheath from the right femoral access was then removed, and we loaded 23 mm ALTO aortic body delivery system over the Lunderquist wire, and advanced it until the implant radiopaque markers were about 1 cm proximal to the intended landing site, we oriented the device positioned appropriately for the access to the contralateral aortic body limb.
We retracted delivery system out the sheath beyond the marker about 2 cm proximal to the handle.
We then deployed first segment of the proximal stent. Then reinflated the balloon through the dedicated port with 5 mL of diluted contrast to open the mid crown and then deflated the integral balloon, then precisely positioned implant radiopaque markers compensation for parallax at final proximal landing site. Reminder of the proximal stent was then deployed.
Removed Green cap from the polymer injection port on the handle and attached diffuser to it.
We used angled Glidewire to cannulate the contralateral limb from left femoral approach, advancing the pigtail catheter to the contralateral limb, and performing angiogram through it to confirm the position, then pushing the catheter to the thoracic aorta and placing 2nd 300 cm Lunderquist wire over the pigtail catheter.
We then inserted the marker catheter into the left iliac artery and performed angiogram to confirm contralateral limb length, we then placed 12 French sheath over the Lunderquist wire to the proximal external iliac artery, loaded the 28 x 12 cm iliac limb delivery system over the contralateral guidewire confirmed proximal and distal limb radiopaque markers to the appropriate location, and deployed the iliac limb extension to the left common iliac artery.
We then released the catheter from alto aortic body and then steadily pulled the knob and wire from the handle, we then stabilize the system, and retracted the catheter handle to reset nosecone into the end of the delivery system, which was removed, and 14 French sheath was placed to the right femoral artery, then we again placed the marker catheter to the right iliac artery, performed right iliac angiogram, loaded that 18 x 12 cm iliac limb delivery system over the Lunderquist wire, confirmed proximal and distal limb radial pack markers to the appropriate location, and deployed the iliac limb extension to the right common iliac artery right above the bifurcation to hypogastric and external iliac artery.
We then placed 2 Reliant balloons balloons respectively to the right and left limbs of the bifurcating aortic graft, and performed sequential kissing balloon inflation of the entire right and left leg of the bifurcating graft, 3 inflations were made.
We then placed pigtail catheter from the left femoral approach to the descending aorta, positioned to the origin of the renal arteries, and performed final angiogram with 15 cc of contrast with power injection, in 5 degree cranial and 30 degree LAO view.
There was excellent graft position, there was no evidence of type I A or IB endoleak, no type III endoleak, no extravasation or dissection.
Then over the tiger wire the 14 French sheath from the right femoral artery was removed, and sutures tightened, and excellent hemostasis was achieved.
Again over the tiger wire the 12 French sheath was removed from the left femoral artery, sutures tightened, and excellent hemostasis was achieved.
The patient was then transferred to the ICC in satisfactory condition.
CONCLUSIONS:
1. Rapidly expanding infrarenal fusiform abdominal aneurysm 4.5 cm in diameter.
2. Successful percutaneous endovascular abdominal aortic aneurysm repair with bifurcating aortic endograft 23 mm ALTO with 28 x 12 cm limb extension on the left, and same 18 x 12 cm limb extension on the right.
3. Patient will continue standard postprocedural follow-up in ICC, with plans to continue dual antiplatelet therapy, and expected discharge tomorrow
Need help with an EVAR -- The codes I'm thinking of are 34705-62 and 34713-50-59. Not sure whether to use 34709 for limb extensions. Any help would be appreciated.
TIA
Procedure:
PERCUTANEOUS ENDOVASCULAR REPAIR OF INFRARENAL AAA, WITH A 23MM BIFURCATING ALTO ENDOGRAFT, VIA RIGHT FEMORAL ARTERY, AND 18 X 12CM OVATION iX LIMB INSERTION VIA RIGHT FEMORAL ARTERY, AND 28 X 12CM OVATION iX LIMB INSERTION VIA LEFT FEMORAL ARTERY
PROCEDURE DESCRIPTION:
After obtaining informed written patient's consent, patient was brought to the hybrid OR suite, and situated on the table. Anesthesia was administered by department of anesthesia, please see separate report. Appropriate timeout was called.
Initial arterial access was obtained to the right femoral artery with ultrasound guidance, and modified Seldinger technique, using micropuncture kit, and 2 Perclose catheters were used for preclosure of the right femoral artery at 10:00, and 2:00, 8 French sheath was introduced. The same technique access to the left femoral artery was obtained, and 2 Perclose catheters were used for preclosure of the left femoral artery, 8 French sheath was introduced.
Patient was heparinized, for ACT more than 250.
Once double access was obtained, we placed 300 cm supra core wire, and then exchanged it over the JR4 catheter to the 300 cm Lunderquist wire from the right femoral access, and from the left femoral artery, a 5 French pigtail measuring catheter was positioned to the abdominal aorta above the origin of renal arteries, and abdominal aortogram was obtained in 5 degree cranial and 30 degree LAO view with power injection of 15 cc of contrast. The origin of the renal arteries was well visualized, and respectively marked. Overall aortic and iliac artery anatomy was reexamined.
The introducer sheath from the right femoral access was then removed, and we loaded 23 mm ALTO aortic body delivery system over the Lunderquist wire, and advanced it until the implant radiopaque markers were about 1 cm proximal to the intended landing site, we oriented the device positioned appropriately for the access to the contralateral aortic body limb.
We retracted delivery system out the sheath beyond the marker about 2 cm proximal to the handle.
We then deployed first segment of the proximal stent. Then reinflated the balloon through the dedicated port with 5 mL of diluted contrast to open the mid crown and then deflated the integral balloon, then precisely positioned implant radiopaque markers compensation for parallax at final proximal landing site. Reminder of the proximal stent was then deployed.
Removed Green cap from the polymer injection port on the handle and attached diffuser to it.
We used angled Glidewire to cannulate the contralateral limb from left femoral approach, advancing the pigtail catheter to the contralateral limb, and performing angiogram through it to confirm the position, then pushing the catheter to the thoracic aorta and placing 2nd 300 cm Lunderquist wire over the pigtail catheter.
We then inserted the marker catheter into the left iliac artery and performed angiogram to confirm contralateral limb length, we then placed 12 French sheath over the Lunderquist wire to the proximal external iliac artery, loaded the 28 x 12 cm iliac limb delivery system over the contralateral guidewire confirmed proximal and distal limb radiopaque markers to the appropriate location, and deployed the iliac limb extension to the left common iliac artery.
We then released the catheter from alto aortic body and then steadily pulled the knob and wire from the handle, we then stabilize the system, and retracted the catheter handle to reset nosecone into the end of the delivery system, which was removed, and 14 French sheath was placed to the right femoral artery, then we again placed the marker catheter to the right iliac artery, performed right iliac angiogram, loaded that 18 x 12 cm iliac limb delivery system over the Lunderquist wire, confirmed proximal and distal limb radial pack markers to the appropriate location, and deployed the iliac limb extension to the right common iliac artery right above the bifurcation to hypogastric and external iliac artery.
We then placed 2 Reliant balloons balloons respectively to the right and left limbs of the bifurcating aortic graft, and performed sequential kissing balloon inflation of the entire right and left leg of the bifurcating graft, 3 inflations were made.
We then placed pigtail catheter from the left femoral approach to the descending aorta, positioned to the origin of the renal arteries, and performed final angiogram with 15 cc of contrast with power injection, in 5 degree cranial and 30 degree LAO view.
There was excellent graft position, there was no evidence of type I A or IB endoleak, no type III endoleak, no extravasation or dissection.
Then over the tiger wire the 14 French sheath from the right femoral artery was removed, and sutures tightened, and excellent hemostasis was achieved.
Again over the tiger wire the 12 French sheath was removed from the left femoral artery, sutures tightened, and excellent hemostasis was achieved.
The patient was then transferred to the ICC in satisfactory condition.
CONCLUSIONS:
1. Rapidly expanding infrarenal fusiform abdominal aneurysm 4.5 cm in diameter.
2. Successful percutaneous endovascular abdominal aortic aneurysm repair with bifurcating aortic endograft 23 mm ALTO with 28 x 12 cm limb extension on the left, and same 18 x 12 cm limb extension on the right.
3. Patient will continue standard postprocedural follow-up in ICC, with plans to continue dual antiplatelet therapy, and expected discharge tomorrow