Unsure of coding of this surgery. Please help!!!
OPERATIVE PROCEDURE:
1. Open exposure of left axillofemoral bypass graft via infraclavicular approach.
2. Angiogram of left axillofemoral bypass graft.
3. Rotational atherectomy of mid graft and distal graft stenosis.
4. Percutaneous transluminal angioplasty of mid graft stenosis using a 7 x 60 mm drug coated balloon (In.pact balloon).
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the
catheterization lab and placed in a supine position with the arms tucked. General anesthesia was administered and the left chest wall and the left neck were prepped and draped in a sterile fashion. After performing an appropriate time-out, I used the ultrasound to locate the course of the graft in the infraclavicular region and in the area of the cephalad portion of her left breast. This was marked and a transverse incision was made just inferior to her old
infraclavicular incision. This was carried down through the skin and subcutaneous tissue, breast tissue to the
pectoralis major fascia. This was divided and the graft was identified and circumferentially dissected and vessel loops were passed around it proximally and distally through the incision. At this point percutaneous access of the graft was obtained using the micropuncture needle wire and micropuncture sheath. Then a stiff Glidewire was
passed through the micropuncture sheath through the lesion and down to the left groin. The micropuncture catheter was then removed and a 7-French sheath, that was approximately 23 cm in length was passed to just proximal to the stenotic area in the mid graft. At this point the patient was systemically heparinized with 9,000 units of intravenous heparin and was bolused roughly every 45 minutes to maintain the anticoagulation. At this point a hand injection through the side port of the 7-French sheath was used to localize the area of stenosis.
This was marked. The stiff Glidewire was then exchanged for an 014 stiff wire. I then used the rotational atherectomy device jet stream, first with the blades down configuration and then the blades out configuration through the area of stenosis. I then took pictures of the distal portion of the graft just before its anastomosis with
the left common femoral artery. This revealed a less severe stenosis that was also atherectomized using the blades down and the blades out configuration. At this point the previous area in the mid graft was marked again and was balloon angioplastied with the Medtronic In.pact balloon that measures 7 x 60 mm. This is a drug coated balloon. This was insufflated and held for 3 minutes. I then advanced the balloon down to the stenosis in the distal portion of the graft and balloon angioplastied this area for roughly 1 minute. At this point the balloon was taken out of the sheath and final imaging of the area showed excellent resolution of the stenosis both in the mid graft
portion and the distal portion of the graft. At this point the wire and balloon were pulled. A 5-0 Prolene stitch was used in a U configuration around the entry point of the 7-French sheath in the graft and it was tied down as the
sheath was removed. This gave us hemostasis at the area of access. Gelfoam soaked with thrombin was
placed around the graft and in the operative field. The patient was then given 50 mg of protamine to reverse the systemic heparin. The wound was then copiously irrigated with normal saline and closed in layers using 2-0 Vicryl to reapproximate the pectoralis fascia and 2-0 and 3-0 Vicryl in the subcutaneous tissue and a running 4-0
Monocryl in a subcuticular fashion. Dermabond and a dry sterile dressing were then placed over the
incision. The patient was awoken from anesthesia in stable condition and she had excellent Doppler signals of both the left dorsalis pedis and left posterior tibial arteries. Patient was then taken to the recovery room.
OPERATIVE PROCEDURE:
1. Open exposure of left axillofemoral bypass graft via infraclavicular approach.
2. Angiogram of left axillofemoral bypass graft.
3. Rotational atherectomy of mid graft and distal graft stenosis.
4. Percutaneous transluminal angioplasty of mid graft stenosis using a 7 x 60 mm drug coated balloon (In.pact balloon).
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the
catheterization lab and placed in a supine position with the arms tucked. General anesthesia was administered and the left chest wall and the left neck were prepped and draped in a sterile fashion. After performing an appropriate time-out, I used the ultrasound to locate the course of the graft in the infraclavicular region and in the area of the cephalad portion of her left breast. This was marked and a transverse incision was made just inferior to her old
infraclavicular incision. This was carried down through the skin and subcutaneous tissue, breast tissue to the
pectoralis major fascia. This was divided and the graft was identified and circumferentially dissected and vessel loops were passed around it proximally and distally through the incision. At this point percutaneous access of the graft was obtained using the micropuncture needle wire and micropuncture sheath. Then a stiff Glidewire was
passed through the micropuncture sheath through the lesion and down to the left groin. The micropuncture catheter was then removed and a 7-French sheath, that was approximately 23 cm in length was passed to just proximal to the stenotic area in the mid graft. At this point the patient was systemically heparinized with 9,000 units of intravenous heparin and was bolused roughly every 45 minutes to maintain the anticoagulation. At this point a hand injection through the side port of the 7-French sheath was used to localize the area of stenosis.
This was marked. The stiff Glidewire was then exchanged for an 014 stiff wire. I then used the rotational atherectomy device jet stream, first with the blades down configuration and then the blades out configuration through the area of stenosis. I then took pictures of the distal portion of the graft just before its anastomosis with
the left common femoral artery. This revealed a less severe stenosis that was also atherectomized using the blades down and the blades out configuration. At this point the previous area in the mid graft was marked again and was balloon angioplastied with the Medtronic In.pact balloon that measures 7 x 60 mm. This is a drug coated balloon. This was insufflated and held for 3 minutes. I then advanced the balloon down to the stenosis in the distal portion of the graft and balloon angioplastied this area for roughly 1 minute. At this point the balloon was taken out of the sheath and final imaging of the area showed excellent resolution of the stenosis both in the mid graft
portion and the distal portion of the graft. At this point the wire and balloon were pulled. A 5-0 Prolene stitch was used in a U configuration around the entry point of the 7-French sheath in the graft and it was tied down as the
sheath was removed. This gave us hemostasis at the area of access. Gelfoam soaked with thrombin was
placed around the graft and in the operative field. The patient was then given 50 mg of protamine to reverse the systemic heparin. The wound was then copiously irrigated with normal saline and closed in layers using 2-0 Vicryl to reapproximate the pectoralis fascia and 2-0 and 3-0 Vicryl in the subcutaneous tissue and a running 4-0
Monocryl in a subcuticular fashion. Dermabond and a dry sterile dressing were then placed over the
incision. The patient was awoken from anesthesia in stable condition and she had excellent Doppler signals of both the left dorsalis pedis and left posterior tibial arteries. Patient was then taken to the recovery room.
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