lovetocode
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Please advise with coding. Thanks in advance (I know its a long op report)!!! I know I can code 35371 for the femoral thrombroendarterectomy, but I am unsure of angioplasties.
PREOPERATIVE DIAGNOSIS:
Bilateral lower extremity claudication and rest pain in left lower extremity.
POSTOPERATIVE DIAGNOSIS:
Bilateral lower extremity claudication and rest pain in left lower extremity.
OPERATION PERFORMED:
1. Bilateral common femoral thromboendarterectomy with Dacron patch
angioplasty.
2. Retrograde aortoiliac angiogram.
3. Bilateral lower extremity runoff.
4. Percutaneous transluminal angioplasty of left common and external iliac, 6
x 4 balloon.
5. Percutaneous transluminal angioplasty of right common iliac and external
iliac, 5 x 4 and 6 x 4 balloons.
INDICATIONS FOR OPERATION:
This is a 61-year-old male with a diffuse history of atherosclerotic disease,
multiple prior revascularizations including a prior right femoral-to-popliteal
artery bypass graft, who has had progressive worsening of his claudication,
deterioration of his ABIs and now has an ABI of 0.3 on the left with rest pain
and claudication in the left leg and claudication on the right.
DESCRIPTION OF OPERATION:
With the patient in the supine position under general anesthesia, time-out
protocols were observed. Monitoring lines were placed by Anesthesia and a
Foley catheter by the OR staff. He was prepped and draped appropriately. Time-
out protocols were observed. Intravenous antibiotics were administered. With
the supplementation with additional local Marcaine, the left groin was opened
obliquely. The common, superficial and profunda femoris arteries were
dissected out, found to be extremely hard and calcified and with palpable near
total obliteration of the common femoral artery on the left side extending up
into the external iliac. The inguinal ligament was mobilized and retracted,
and the external iliac was mobilized to a distance of about 5-6 cm until an
area of a softer and clampable vessel was obtained.
The patient was fully heparinized. The femoral bifurcation vessels were
clamped. The external iliac was clamped and an opening was made in the common
femoral artery, extended up onto the proximal external iliac into a point where
there was a significant residual lumen of the external iliac. The common
femoral had no significant residual lumen, although there was some lumen.
Endarterectomy was then performed, carried down to the femoral bifurcation
where the plaque was transected and the orifice of the profunda and SFA were
tacked down. A Hemashield Dacron patch was sutured on as on onlay patch using
a running 5-0 Prolene suture with standard techniques. Prior to completion of
closure, flushing maneuvers were performed. Closure was completed. Clamps
were removed, and improved although not excellent flow was noted in the common
femoral artery. This was now pulsatile and had better Doppler characteristics
than had been present performed.
The artery was then accessed through the patch using a micropuncture needle,
wire and sheath under fluoroscopic direction with the sheath placed up into the
external iliac artery. Retrograde angiography showed significant diffuse
disease involving the external, iliac and common iliac arteries. An 0.035 wire
was passed into the abdominal aorta. An angiogram was done that actually
showed the distal aorta and some spillover into the right side, which also was
heavily diseased. The sheath was upsized to a standard 5-French sheath and
then a 6 x 4 balloon was passed into the abdominal aorta and then withdrawn
into the iliac origin, and sequential handheld injections of the iliac
throughout its length were performed all the way back down to the level of the
endarterectomy of the femoral artery. When this was complete, there was an
excellent pulse in the groin not present previously, and retrograde angiography
showed diffuse improvement of the whole iliac system.
The balloon was removed. The sheath was removed and a Prolene suture was used
to control bleeding from the patch. Several additional sutures were required
with the increased pressure head to complete hemostasis, and at this point
there was diffuse generalized oozing from the tissues with no specific areas of
bleeding that could be well visualized or controlled, and this continued
throughout the case until the end of the case when the heparin was finally
reversed. Topical thrombostatic agents were used intermittently, as well as
packing with gauzes to help control bleeding, but a significant amount of blood
loss occurred through the left groin throughout the course of the remainder of
this case. Having corrected the left-sided inflow problems, handheld
injections were used to visualize the runoff, which consisted of superficial
femoral artery, popliteal, and 3-vessel runoff all the way to the ankle, all of
which appeared be open with no critical lesions noted. This was done prior to
sheath removal.
Sheath was also not yet removed prior to an attempt at doing over-the-top
angioplasty of the right side. The following procedures were done: With the
0.035 wire in place, a UF catheter was placed in the aorta. The bifurcation
was well calcified, and retrograde pictures previously had shown the aortic
bifurcation. Therefore, the aortic bifurcation was crossed with an 0.035
Bentson and then Glide and the UF catheter followed by a Berenstein catheter.
Angiograms were performed through this demonstrating an open and diseased
common and external iliac with fairly significant disease of the common iliac
and a portion of the common femoral just proximal to the origin of the fem-pop
graft on the right side. Attempts at getting enough wire down beyond this
point to allow intervention using balloon and/or stent therapy were
unsuccessful. Decision was made therefore to perform open procedure,
particularly with the involvement of the common femoral artery. The sheath was
then removed as described previously and the wound packed.
On the right side, there was significant scarring. The area of the previous
scar was reopened after infiltrating with 0.5% Marcaine with epinephrine,
carried down through the skin and subcutaneous tissues down to the level of the
hood of the fem-pop graft, which was then followed down to the common femoral
artery. The common femoral artery was then dissected out down to the
bifurcation, exposing the origins of the SFA and the profunda femoris. It was
possible to place a clamp across these at this point to provide for distal
control. Proximally, the common femoral was encircled and then dissected free
up to the inguinal ligament and farther dissection carried up under the
external iliac. It was recognized that the whole external iliac was diseased,
and so the plan was simply to remove the common femoral plaque and the worst of
the distal external iliac plaque. Clamps were placed on the external iliac
accordingly, as well as the femoral bifurcation and the fem-pop graft. This
opening was then made through the hood of the fem-pop graft, the only soft part
of the artery, and then extended up onto the heavily diseased common femoral
artery.
Again there was severe disease, but in this side there was a residual lumen,
and with the position of the arteriotomy, it was possible to see that there was
a satisfactory origin of the profunda femoris. The SFA was chronically
occluded except for the proximal stump, and the decision was therefore made to
debride away some of the plaque but not to perform a complete endarterectomy at
the femoral bifurcation level because of the danger of extending down into the
profunda femoris artery, which was heavily scarred in. Accordingly, after
debriding the plaque and tacking it, a Dacron patch was brought onto the field
and sutured on as an onlay patch using running 5-0 Prolene in standard
techniques. Some aspects of this anastomosis were somewhat difficult because
of the severity of the calcification. Upon completion of this, flushing
maneuvers were performed. Closure was completed, clamps removed and flow
allowed again to the femoral bifurcation. Again there was some improvement in
pulsatility in the groin, but far from ideal and far from normal.
The hood of the graft was then accessed percutaneously using a micropuncture
needle, wire and sheath, which were threaded retrograde up into the external
iliac artery. An 0.035 wire, ultimately an Amplatz wire, was placed up into
the external iliac, the common iliac and up into the aorta. Retrograde
angiography confirmed the findings previously noted, and then a 5 mm x 4 cm
balloon was used to balloon the full length of the iliac artery down into the
area of the endarterectomy and patch. Upon completion of this, retrograde
angiography showed some persistent disease at the upper end of the
endarterectomy site, and therefore the 6 balloon was placed over the Amplatz
wire into this area, inflated to profile, held for several minutes and then
deflated with a significant improvement in the profile. Retrograde angiography
at this time appeared improved and prograde flow was excellent as witnessed by
increasing needle hole bleeding and a very strong pulse in the groin. The
sheath and wire were now removed from the hood of the bypass graft, which was
then repaired with Prolene.
Hemostasis in this wound was also somewhat problematic because of the patient's
of antiplatelet therapy. Topical thrombin static agents include Surgicel,
Gelfoam, thrombin and FloSeal. Heparin was reversed after ascertaining there
were excellent Doppler signals at both ankles at the posterior tibial level.
With full reversal of the heparin and the patient and persistent use of topical
thrombostatic agents and several additional sutures along the suture line,
hemostasis was finally achieved. The wounds were irrigated with saline. The
subcutaneous tissue was closed in layers of Vicryl and the skin closed with
Monocryl. Sterile dressings were applied. Needle and sponge counts were
correct. The procedure was well tolerated, and the patient returned to the VICU
in stable condition.
PREOPERATIVE DIAGNOSIS:
Bilateral lower extremity claudication and rest pain in left lower extremity.
POSTOPERATIVE DIAGNOSIS:
Bilateral lower extremity claudication and rest pain in left lower extremity.
OPERATION PERFORMED:
1. Bilateral common femoral thromboendarterectomy with Dacron patch
angioplasty.
2. Retrograde aortoiliac angiogram.
3. Bilateral lower extremity runoff.
4. Percutaneous transluminal angioplasty of left common and external iliac, 6
x 4 balloon.
5. Percutaneous transluminal angioplasty of right common iliac and external
iliac, 5 x 4 and 6 x 4 balloons.
INDICATIONS FOR OPERATION:
This is a 61-year-old male with a diffuse history of atherosclerotic disease,
multiple prior revascularizations including a prior right femoral-to-popliteal
artery bypass graft, who has had progressive worsening of his claudication,
deterioration of his ABIs and now has an ABI of 0.3 on the left with rest pain
and claudication in the left leg and claudication on the right.
DESCRIPTION OF OPERATION:
With the patient in the supine position under general anesthesia, time-out
protocols were observed. Monitoring lines were placed by Anesthesia and a
Foley catheter by the OR staff. He was prepped and draped appropriately. Time-
out protocols were observed. Intravenous antibiotics were administered. With
the supplementation with additional local Marcaine, the left groin was opened
obliquely. The common, superficial and profunda femoris arteries were
dissected out, found to be extremely hard and calcified and with palpable near
total obliteration of the common femoral artery on the left side extending up
into the external iliac. The inguinal ligament was mobilized and retracted,
and the external iliac was mobilized to a distance of about 5-6 cm until an
area of a softer and clampable vessel was obtained.
The patient was fully heparinized. The femoral bifurcation vessels were
clamped. The external iliac was clamped and an opening was made in the common
femoral artery, extended up onto the proximal external iliac into a point where
there was a significant residual lumen of the external iliac. The common
femoral had no significant residual lumen, although there was some lumen.
Endarterectomy was then performed, carried down to the femoral bifurcation
where the plaque was transected and the orifice of the profunda and SFA were
tacked down. A Hemashield Dacron patch was sutured on as on onlay patch using
a running 5-0 Prolene suture with standard techniques. Prior to completion of
closure, flushing maneuvers were performed. Closure was completed. Clamps
were removed, and improved although not excellent flow was noted in the common
femoral artery. This was now pulsatile and had better Doppler characteristics
than had been present performed.
The artery was then accessed through the patch using a micropuncture needle,
wire and sheath under fluoroscopic direction with the sheath placed up into the
external iliac artery. Retrograde angiography showed significant diffuse
disease involving the external, iliac and common iliac arteries. An 0.035 wire
was passed into the abdominal aorta. An angiogram was done that actually
showed the distal aorta and some spillover into the right side, which also was
heavily diseased. The sheath was upsized to a standard 5-French sheath and
then a 6 x 4 balloon was passed into the abdominal aorta and then withdrawn
into the iliac origin, and sequential handheld injections of the iliac
throughout its length were performed all the way back down to the level of the
endarterectomy of the femoral artery. When this was complete, there was an
excellent pulse in the groin not present previously, and retrograde angiography
showed diffuse improvement of the whole iliac system.
The balloon was removed. The sheath was removed and a Prolene suture was used
to control bleeding from the patch. Several additional sutures were required
with the increased pressure head to complete hemostasis, and at this point
there was diffuse generalized oozing from the tissues with no specific areas of
bleeding that could be well visualized or controlled, and this continued
throughout the case until the end of the case when the heparin was finally
reversed. Topical thrombostatic agents were used intermittently, as well as
packing with gauzes to help control bleeding, but a significant amount of blood
loss occurred through the left groin throughout the course of the remainder of
this case. Having corrected the left-sided inflow problems, handheld
injections were used to visualize the runoff, which consisted of superficial
femoral artery, popliteal, and 3-vessel runoff all the way to the ankle, all of
which appeared be open with no critical lesions noted. This was done prior to
sheath removal.
Sheath was also not yet removed prior to an attempt at doing over-the-top
angioplasty of the right side. The following procedures were done: With the
0.035 wire in place, a UF catheter was placed in the aorta. The bifurcation
was well calcified, and retrograde pictures previously had shown the aortic
bifurcation. Therefore, the aortic bifurcation was crossed with an 0.035
Bentson and then Glide and the UF catheter followed by a Berenstein catheter.
Angiograms were performed through this demonstrating an open and diseased
common and external iliac with fairly significant disease of the common iliac
and a portion of the common femoral just proximal to the origin of the fem-pop
graft on the right side. Attempts at getting enough wire down beyond this
point to allow intervention using balloon and/or stent therapy were
unsuccessful. Decision was made therefore to perform open procedure,
particularly with the involvement of the common femoral artery. The sheath was
then removed as described previously and the wound packed.
On the right side, there was significant scarring. The area of the previous
scar was reopened after infiltrating with 0.5% Marcaine with epinephrine,
carried down through the skin and subcutaneous tissues down to the level of the
hood of the fem-pop graft, which was then followed down to the common femoral
artery. The common femoral artery was then dissected out down to the
bifurcation, exposing the origins of the SFA and the profunda femoris. It was
possible to place a clamp across these at this point to provide for distal
control. Proximally, the common femoral was encircled and then dissected free
up to the inguinal ligament and farther dissection carried up under the
external iliac. It was recognized that the whole external iliac was diseased,
and so the plan was simply to remove the common femoral plaque and the worst of
the distal external iliac plaque. Clamps were placed on the external iliac
accordingly, as well as the femoral bifurcation and the fem-pop graft. This
opening was then made through the hood of the fem-pop graft, the only soft part
of the artery, and then extended up onto the heavily diseased common femoral
artery.
Again there was severe disease, but in this side there was a residual lumen,
and with the position of the arteriotomy, it was possible to see that there was
a satisfactory origin of the profunda femoris. The SFA was chronically
occluded except for the proximal stump, and the decision was therefore made to
debride away some of the plaque but not to perform a complete endarterectomy at
the femoral bifurcation level because of the danger of extending down into the
profunda femoris artery, which was heavily scarred in. Accordingly, after
debriding the plaque and tacking it, a Dacron patch was brought onto the field
and sutured on as an onlay patch using running 5-0 Prolene in standard
techniques. Some aspects of this anastomosis were somewhat difficult because
of the severity of the calcification. Upon completion of this, flushing
maneuvers were performed. Closure was completed, clamps removed and flow
allowed again to the femoral bifurcation. Again there was some improvement in
pulsatility in the groin, but far from ideal and far from normal.
The hood of the graft was then accessed percutaneously using a micropuncture
needle, wire and sheath, which were threaded retrograde up into the external
iliac artery. An 0.035 wire, ultimately an Amplatz wire, was placed up into
the external iliac, the common iliac and up into the aorta. Retrograde
angiography confirmed the findings previously noted, and then a 5 mm x 4 cm
balloon was used to balloon the full length of the iliac artery down into the
area of the endarterectomy and patch. Upon completion of this, retrograde
angiography showed some persistent disease at the upper end of the
endarterectomy site, and therefore the 6 balloon was placed over the Amplatz
wire into this area, inflated to profile, held for several minutes and then
deflated with a significant improvement in the profile. Retrograde angiography
at this time appeared improved and prograde flow was excellent as witnessed by
increasing needle hole bleeding and a very strong pulse in the groin. The
sheath and wire were now removed from the hood of the bypass graft, which was
then repaired with Prolene.
Hemostasis in this wound was also somewhat problematic because of the patient's
of antiplatelet therapy. Topical thrombin static agents include Surgicel,
Gelfoam, thrombin and FloSeal. Heparin was reversed after ascertaining there
were excellent Doppler signals at both ankles at the posterior tibial level.
With full reversal of the heparin and the patient and persistent use of topical
thrombostatic agents and several additional sutures along the suture line,
hemostasis was finally achieved. The wounds were irrigated with saline. The
subcutaneous tissue was closed in layers of Vicryl and the skin closed with
Monocryl. Sterile dressings were applied. Needle and sponge counts were
correct. The procedure was well tolerated, and the patient returned to the VICU
in stable condition.