Help.....multiple endarterectomies same leg, different vessels

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Woodstock, GA
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I need opinions on the operative note below. The physician states doing and endarterectomy of the SFA/PFA/popliteal/tib-peroneal truck/orifice of the ant tibial/and the posterior tibial vessels. He makes two incisions in the common femoral and the popliteal. And I know i cannot bill for contiguous lesions, but I am not sure that I can bill for all the vessels listed above. Any opinions would help. thanks in advance


PROCEDURE

1. Remote endarterectomy, superficial femoral and popliteal arteries.

2. Bovine patch angioplasty of the common femoral and the superficial

femoral artery proximally.

3. Endarterectomy of the tibioperoneal trunk, orifice of the anterior

tibial, and posterior tibial.

4. Vein patch angioplasty from the popliteal tibioperoneal trunk onto

the posterior tibial.

5. Amputation of the right hallux at the transmetatarsal level.

6. Amputation of 2nd toe proximal interphalangeal joint.



ANESTHESIA: General endotracheal.



ESTIMATED BLOOD LOSS: 550 mL.



URINE OUTPUT: 1400 mL.



HEPARIN: 7000 units.



FLUIDS: Crystalloid 3700 mL.



FINDINGS: Extensive occlusions flush with the superficial femoral

artery onto an occluded anterior tibial and tibioperoneal trunk. A 2+

posterior tibial pulse at the end of the case. Palpable distal

anterior tibial Doppler signal.



SPECIMEN: Gangrenous right 1st and 2nd toe, 1st toe for osteo.



CONDITION: The patient tolerated the procedure.



DESCRIPTION OF PROCEDURE: The patient was brought to the operating

room, placed in the supine position. After introduction of general

endotracheal anesthesia, the right lower extremity was prepped and

draped in the usual sterile manner. The patient came in with

gangrenous right 1st and 2nd toe, ischemic right foot. Had iliac

angioplasty and stents last week, a coronary angioplasty and stent

before that and is now ready for a distal bypass. Procedure, risks,

and benefits of an in situ bypass versus remote endarterectomy and

patch were explained and accepted by the patient as well as

amputation. Procedure, risks were all explained and accepted.



After prepping and draping, we imaged the vein and mapped it out with

a marking pen. So we then made an incision below the knee through the

skin and subcutaneous tissue. Vein was dissected out between branches.

Branches were taken between 4-0 silks and clips, and mobilized. We

then deepened the incision to the popliteal artery. Popliteal artery

was pulseless. We came around it; however, it was not as calcified. It

was kind of a soft plaque. We dissected around the anterior tibial,

came with a loop. We then mobilized the vein and came under the vein

and clipped the loops underneath and then dissected out the entire

tibioperoneal trunk, which was inflamed. We got around the peroneal

and the posterior tibial as well. There was a branch that was on the

angiogram that was keeping the posterior tibial, and we came around

that with a 2-0 silk. After mobilizing it, which took quite some time,

we heparinized the patient with 5000 units of sodium heparin, 3

minutes waited in circulation time, and made a longitudinal

arteriotomy and a distal arteriotomy in the distal popliteal artery,

enlarged with a Potts scissor. We came around with a core and using a

Freer elevator, dissecting out and around the core and then Vollmar

ring dissector, the smallest one we had, a 5 mm, came around with

fluoroscopy with a sterile sleeve, and we were able to see that we

were able to get the Vollmar ring dissector up with that. We left ring

dissector and looped up and did a cut down in the right groin. An

incision was made through the skin and subcutaneous tissue with a 15

blade scalpel. Dissection was carried down. Large lymph nodes were

noted. These were all from the previous gangrenous changes and the

wounds in his feet. All the nodes were left intact. At the end of the

procedure, they were actually taken with ties to try to make sure he

did not get a lymph leak. Weitlaner retractors were placed. The common

femoral artery was soft and then the SFA was pulseless. We came around

the common femoral with a blue loop. The profunda femoris artery,

there were 2 branches, one medially and laterally just at the takeoff

of the superficial femoral artery and approximately 4 cm of

superficial femoral artery was then dissected out. We then made a

longitudinal arteriotomy with an 11 blade scalpel, enlarged with a

Potts scissor. We formed an endarterectomized plane with a Freer

elevator, came around, transected the plaque proximally. We put a

clamp on, and put the Vollmar ring and came from above, took it out

from below, got a chunk of plaque and then came from above with

fluoroscopy, went all way down to our loop and the below-knee

popliteal and then took out the remaining portion of the core. We then

passed a #4 Fogarty catheter. We got a lot of grumous out. We shot

pictures with Visipaque and half-half dye, and showed no perforation,

and complete flow down to the level of the popliteal artery. With

that, we wanted to save as much vein as possible and continue to

bypass at a later date.



A bovine patch was brought into the field. Bovine patch angioplasty

was then performed. We did put 1 tacking suture in the medial wall of

the common femoral to tack down the plaque. All debris was

meticulously removed with heparin irrigation, loupe magnification, and

then a bovine patch angioplasty was performed with 6-0 Prolene on a BV

needle. Prior to completing, all air and debris were flushed and

BioGlue was used to seal the anastomosis. Flow was restored back into

the profunda femoris artery and then down the leg. We heparinized it

multiple times and flushed it on the distal part. We then opened the

artery onto the orifice of the anterior tibial, which was completely

occluded. We did an eversion endarterectomy of the anterior tibial

artery, got back bleeding, were able to pass a Fogarty catheter down

onto the foot. This was then heparinized and a Yasargil clip placed on

the anterior tib. We could not get and end point on the tibioperoneal

trunk, and the tibioperoneal trunk was completely occluded, so we

dissected down to just beyond the bifurcation of the peroneal and

posterior tib, where we got actually fairly good end point and good

backbleeding from the posterior tibial and was able to pass a 2

Fogarty catheter down to the foot from the posterior tibial at that

point. We then took a portion of vein that was previously dissected

out. The vein at the end point trifurcated and essentially was occluded and sclerotic. One

was minimally open; the rest were sclerotic and nonusable. So then we

doubly clipped the vein more proximally, took it out, and reversed it,

and opened it up for a patch and did an extensive vein patch

angioplasty from the popliteal artery down onto the posterior tibial

artery, encompassing the orifice of the anterior tibial artery,

peroneal, and then posterior tibial artery. All debris was

meticulously removed of the endarterectomized segment prior. Large

amounts of heparin irrigation was used throughout because the patient

was extremely oozy due to his Plavix, and then we did this vein patch

angioplasty. Prior to completing it, we did remove the loop on the

posterior tibial, sent a Fogarty with a 3-way stopcock, 2 Fogarty

catheter down to the foot and came back and left that in place until

only a small segment was open. We flushed prograde in the anterior tib

and prograde from the SFA and had a rush of arterial blood. We

heparinized once again, completing the anastomosis, BioGlued the

majority of it as well, and then restored flow. A palpable pulse was

immediately apparent in the posterior tibial and good Doppler signal

was noted at the ankle mortise in the anterior tibial. Hemostasis was

obtained with Gelfoam and thrombin in the wound. Some tacking sutures

were used of 6-0 Prolene, both in the groin and on the vein patch. The

patient, as stated, was extremely oozy. He was oozing and all

these nodes that were dissected around were taken on the medial side

of the patient with 2-0 silks up in the groin. The groin was

irrigated. It had oozed throughout the entire case. The majority of

blood loss was probably from the groin oozing. We put some tacking

sutures in the patch and finally got good hemostasis with multiple

rounds of Gelfoam and thrombin and irrigation and then closed the

groin with multiple layers of 3-0 Vicryl, 4-0 Vicryl, and a 4-0

Monocryl. Dermabond on the groin, and then covered it with AFM and

Tegaderms to seal it. Below, we placed a 1/8-inch drain, brought it

out through a separate stab wound and attached it to the skin with a 2-

0 silk suture. After adequate hemostasis and irrigating with copious

amounts of antibiotic irrigation, we closed some loose muscles with 3-

0 Vicryl interrupted, and then a running 3-0 Vicryl deep suture, a 4-0

Vicryl in a superficial suture, and skin clips. We then applied AFM

and Tegaderms as well.[/LEFT][/LEFT]
 
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