Help coding Please fem fem Bypass Please.

Robbin109

Expert
Messages
337
Location
San Diego
Best answers
0
35302
35661
??


Operation:

1. Left to right Femoral Femoral Bypass with 6 mm ringed Propaten Graft
2. Right Common femoral extended endarterectomy
3. Fogarty embolectomy right SFA
4. Left Common Femoral to Superficial Femoral bypass with 6mm ringed Propaten Graft
5. Left Profundaplasty
6. Modifier for redo surgery, extensive

Technique

After informed consent was obtained, and the patient was marked, the patient was taken to the OR at Pomerado on 10/6/2016.
After general anesthesia, radial arterial line, and foley catheter was placed, the patient was prepped and draped in the usual sterile
fashion from the umbilicus to the toes bilaterally.
Then next, a vertical incision was made in the right femoral region. The incision was taken down to the subcutaneous level with 15
blade and cautery. The tissue from the fascia down to the femoral sheath was extremely scarred and adhesed from previous
operations. This dissection was tedious and somewhat difficult. The right SFA was cleared and controlled, and then the dissection
proceeded cephalad and the profunda and CFA were skeletonized and controlled. Vessel loops placed. The CFA was occluded and
firm plaque was noted.
Then next, the left femoral region was addressed. The incision was taken down to the subcutanous level with 15 blade and
cautery. The tissue from the fascia down to the femoral sheath was extremely scarred and adhesed from previous operations. This
dissection was tedious and somewhat difficult. The adhesions on this side were worse than the right. The left SFA was cleared and
controlled, and then the dissection proceeded cephalad and the profunda and CFA were skeletonized and controlled. There were
two large Profunda branches and the dissection here was very difficult due to scarring. There was a good pulse from the profunda
and CFA, but the arteries themselves were thin.
Then next, a 6 mm x 80 ringed Propaten graft was tunnelled from the left femoral to the right femoral region in a gentle, curved
manner. The patient was then systemically heparinized with 9700 units IV heparin. The ACT was measured every 25-30 minutes,
and the ACT level was kept above 250 seconds. A total of 21,000 units of IV heparin was utilized during this case. The vessels
were then occluded on the left side with vascular clamps. The CFA was opened, and from the inside, there was a large plaque at
origin of Profunda. Thus a profundaplasty was performed, and good backbleeding was noted from Profunda following this. The
distal edge of arteriotomy was very friable, and thin. The Propaten was cut to size and spatulated, and the left CFA-Graft
anastomosis was perfomed with 6-0 Prolene. A clamp was placed on the graft on the right side, and the proximal clamp was
removed. Extensive bleeding from the friable proximal SFA was noted. Sutures at the toe of the graft were pulling through due to
the frailty of this tissue. Thus a decision was made to ligate SFA at the origin and at the end of the anastomosis. The profunda
flow was excellent. Bleeding points on the anastomosis was addressed with repair suture with plegets for added security of sutures.
A separate piece of the Propaten was brought to the field, and cut to size. The proximal cross femoral bypass was clamped
between clamps and a graftotomy was made with a 11 blade. The separate piece of Propaten was brought to the field, and graft to
graft anastomosis was made with 6-0 Gore Sutures. The distal end of the graft was clamped and spatulated on the anteior
surface. The left SFA was cleared and mobilized to proximal thigh and spatulated on the posterior side. The graft and SFA was
anastomosed end to end with 6-0 Prolene x 2. Following this, the graft was opened to the profunda limb and the SFA limb
respectively. Good triphasic flow was noted.

Then next, the clamps were placed on the right CFA region, the profunda and SFA. An arteriotomy was made, and a large amount
of hard plaque was noted, and an extended endarterectomy was performed on the CFA, Profunda and proximal SFA. Good back
bleeding was noted in the right profunda, but not so much from the SFA. Thus, a #3 and #4 fogarty catheter was used to perform
2 passes of the embolectomy until good back bleeding was noted. The Propaten fem fem graft on this side was cut to size, and
spatulated, and the graft to the right femoral artery was performed with 6-0 Prolene. The artery was deaired and final sutures tied.
Good mulitphasic signals noted in both lower extremities in both feet. Then next, 30 mg of Protamine was given to reverse the
effects of heparin. Hemostasis was slow, but adjuncts like surgicell and gelfoam and thrombin was utilized. Both groins did have
good hemostasis eventually, and Surgiflo sealants were placed, and the incisions were then closed with 2-0 Vicryl x 2, 3-0 Vicryl,
and staples.

Then next, bilateral Prevena skin vacs were placed, and good suction was noted. The patient tolerated the procedure well, and he
was extubated, and brought to ICU in stable condition.

Indication for Surgery
Right leg rest pain.
 
Top