CTraynham
New
My provider performed an External Iliac to above knee Popliteal bypass with a synthetic graft. There is no defined CPT code that accurately describes this procedure. Should an unlisted code be used?
Procedure was initiated with an oblique incision in the left lower quadrant of the abdomen. Entering the retroperitoneal space the left external iliac artery was identified. Using the Omni retractor device exposure was obtained and the vessel was encircled with elastic vascular tapes proximally and distally.
On the anterior proximal left thigh I made a longitudinal incision with dissection down to the mid left superficial femoral artery. I had hoped to bypass to this area. However, the vessel was noted to be heavily calcified and was not amenable for the bypass procedure.
I then made an incision longitudinally in the distal medial left thigh. Careful sharp and blunt tissue dissection were performed down to the above-knee popliteal artery which was encircled with elastic vascular tapes proximally and distally.
Next a tunnel was created in the subsartorial plane up to the left iliac fossa. A 6 mm ring enforced PTFE graft was then tunneled between the 2 incisions. Great care was taken to ensure that the PTFE graft did not come into contact with any skin. I changed my gloves before touching the graft. After the graft was tunneled 5000 units of heparin were given and allowed to circulate for 5 minutes.
Careful occlusion of the proximal left external iliac artery was performed with a soft jaw vascular clamp and a distal elastic vascular tape. Arteriotomy was made into the left external iliac artery with a #11 blade and extended with the Potts scissors. Soft and calcified plaque was noted in the vessel and careful endarterectomy was performed using a freer elevator. Plaque was sharply divided proximally and removed and sent to pathology for specimen. Next the PTFE graft was sewn to the left external iliac artery with a 5–0 Prolene in a running fashion under loupe magnification. Suture line was completed and tied and flow established through the PTFE graft and was noted to be good. Proximal suture line hemostasis was obtained with the assistance of Surgicel dressing and direct pressure. Graft was occluded just past the proximal anastomosis.
Attention was then placed to the above-knee popliteal artery were Vesseloops were secured. Arteriotomy was made with a #11 blade and extended with the Potts scissors. The distal anastomosis was sewn between the PTFE graft and the artery with 6-0 Prolene suture under loupe magnification. Suture line completed and tied and good flow through the graft was achieved. This was confirmed by use of a Doppler wand. All wounds were then copiously irrigated with warm Ancef solution. The proximal and distal anastomotic suture lines were dry.
Left lower quadrant incision was closed in 3 layers with 2-0 PDS suture and skin closure with subcuticular 4-0 undyed Monocryl. Proximal mid left anterior thigh incision was closed with 2 layers of PDS suture and subcuticular 4-0 undyed Monocryl. In the distal medial thigh incision was closed with 2-0 PDS suture in 2 layers. Skin closure was performed with 4-0 undyed Monocryl. Praveena wound VAC dressings were applied to all wounds.
Procedure was initiated with an oblique incision in the left lower quadrant of the abdomen. Entering the retroperitoneal space the left external iliac artery was identified. Using the Omni retractor device exposure was obtained and the vessel was encircled with elastic vascular tapes proximally and distally.
On the anterior proximal left thigh I made a longitudinal incision with dissection down to the mid left superficial femoral artery. I had hoped to bypass to this area. However, the vessel was noted to be heavily calcified and was not amenable for the bypass procedure.
I then made an incision longitudinally in the distal medial left thigh. Careful sharp and blunt tissue dissection were performed down to the above-knee popliteal artery which was encircled with elastic vascular tapes proximally and distally.
Next a tunnel was created in the subsartorial plane up to the left iliac fossa. A 6 mm ring enforced PTFE graft was then tunneled between the 2 incisions. Great care was taken to ensure that the PTFE graft did not come into contact with any skin. I changed my gloves before touching the graft. After the graft was tunneled 5000 units of heparin were given and allowed to circulate for 5 minutes.
Careful occlusion of the proximal left external iliac artery was performed with a soft jaw vascular clamp and a distal elastic vascular tape. Arteriotomy was made into the left external iliac artery with a #11 blade and extended with the Potts scissors. Soft and calcified plaque was noted in the vessel and careful endarterectomy was performed using a freer elevator. Plaque was sharply divided proximally and removed and sent to pathology for specimen. Next the PTFE graft was sewn to the left external iliac artery with a 5–0 Prolene in a running fashion under loupe magnification. Suture line was completed and tied and flow established through the PTFE graft and was noted to be good. Proximal suture line hemostasis was obtained with the assistance of Surgicel dressing and direct pressure. Graft was occluded just past the proximal anastomosis.
Attention was then placed to the above-knee popliteal artery were Vesseloops were secured. Arteriotomy was made with a #11 blade and extended with the Potts scissors. The distal anastomosis was sewn between the PTFE graft and the artery with 6-0 Prolene suture under loupe magnification. Suture line completed and tied and good flow through the graft was achieved. This was confirmed by use of a Doppler wand. All wounds were then copiously irrigated with warm Ancef solution. The proximal and distal anastomotic suture lines were dry.
Left lower quadrant incision was closed in 3 layers with 2-0 PDS suture and skin closure with subcuticular 4-0 undyed Monocryl. Proximal mid left anterior thigh incision was closed with 2 layers of PDS suture and subcuticular 4-0 undyed Monocryl. In the distal medial thigh incision was closed with 2-0 PDS suture in 2 layers. Skin closure was performed with 4-0 undyed Monocryl. Praveena wound VAC dressings were applied to all wounds.