Help with Repair of EVAR Endoleak and Rt IIAneurysm

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Could someone please advise on correct coding of these procedures? (Extension prosthesis for the limbs and Int Iliac Aneurysm stent graft)

REASON FOR EXAM: graft migration------

PREOPERATIVE DIAGNOSIS: History of ruptured abdominal aortic
aneurysm status
post endovascular repair, now with enlarging aneurysm sac and
endoleak.
POSTOPERATIVE DIAGNOSIS: History of ruptured abdominal aortic
aneurysm
status post endovascular repair, now with enlarging aneurysm sac and
endoleak.
PROCEDURES PERFORMED:
1. Realigning of previous endovascular stent graft.
2. Endovascular repair of aortic aneurysm.
3. Endovascular repair of internal iliac artery aneurysm.
4. Repair of type 4 endoleak.
ANESTHESIA: General.
ACCESS SITE: Left brachial cut down, right common femoral artery,
left
femoral artery.
CONTRAST: 205 mL.
FLUOROSCOPY TIME: 41.6 minutes.
COMPLICATIONS: No immediate complications.
ESTIMATED BLOOD LOSS: Approximately 200 mL.
INDICATION: is an 83-year-old male who had an abdominal
aortic
aneurysm repaired in 2002 and subsequently had rupture in 2013
requiring
extension of his right iliac limb. He has been seen as an outpatient
and was found to have an enlarging aneurysm sac and previous
angiograms and CT scans have confirmed an endoleak. He previously
had a
branch off his left internal iliac artery coiled and embolized to
treat a
type 2 endoleak, but because of the continued aneurysm's growth as
well as
endoleak seen on CT scan, the concern was for a type 4 endoleak from
the
Aneurx device that had been placed previously. Therefore, risks,
benefits
and alternatives for realigning and extending the graft were
discussed with
the patient and his wife and they agreed to the procedure.
DESCRIPTION OF DIAGNOSTIC PROCEDURE: The patient was brought to the
operating room and placed in a supine position. The bilateral groins
and
left upper extremity were prepped and draped in the usual sterile
fashion
using ChloraPrep. Bilateral common femoral arteries were cannulated
under
ultrasound guidance and wires were advanced up through each limb of
the
previous EVAR device into the supraceliac aorta. The tracts were then
serially dilated and the Prostar technique was used to pre-close the
groins.
After this, 12-French sheaths were advanced into the common iliac
artery and
then into the proximal limbs. A left brachial cut down was also
performed in
the proximal upper arm. An incision was made longitudinally parallel
to the
brachial artery, the underlying tissue dissected with electrocautery
down to
the level of the brachial artery and vein. A nerve was identified and
spared. The brachial artery was identified and circumferentially
dissected
out approximately 2 cm and vessel loops were placed proximal and
distal.
Cook needle was used to cannulate the brachial artery and a wire was
advanced
down into the subclavian. Pigtail was then brought down and tracked
over a
wire into the descending thoracic aorta. An abdominal aortogram was
performed and showed a patent endovascular stent graft without
obvious type 1
or type 2 endoleak.
DESCRIPTION OF INTERVENTIONAL PROCEDURE: A 14 x 7 limb was advanced
up the
right iliac limb and deployed proximally just distal to the flow
divider to
cover the previous Aneurx portion of the stent graft. A left 14 x 14
limb
was then advanced up to past the flow divider and deployed within the
left
iliac limb to realign the left limb completely. At this point, wire
was then
passed from the arm down the stent graft device through the right
limb and
into the internal iliac artery. Catheter was passed through this,
angiogram
was performed to confirm that we were in the internal iliac artery.
We then
upsized our sheath to an 11-French sheath and passed a Microvena
wire. We
then attempted to pass a Viabahn stent over this but had difficulty
going
through the sheath, therefore the 11-French sheath was then switched
out to a
12-French sheath over a wire. We were then able to advance a 10 x 10
Viabahn
device into the internal iliac artery. We then deployed this into
the right
limb of our EVAR stent graft. A 13 x 10 Viabahn was then advanced
from the
right groin into the stent graft device and deployed into the
external iliac
artery. An additional 10 x 15 internal iliac artery Viabahn was then
extended up into the right limb matching the internal and external
Viabahns.
These were plastied after deployment distally, then proximally, with
kissing
balloons. Completion angiogram showed complete realignment of the
previous
Aneurx stent graft and extension into the Viabahns into the external
and
internal iliac arteries and no evidence of endoleak. The bilateral
groins
were closed with Prostars and Monocryl was placed at the skin. The
sheath
was pulled from the left arm. The brachial arteriotomy was closed
with 6-0
Prolene in a running fashion. Hemostasis was verified. The deep
fascia was
closed with 3-0 Vicryl. The dermis was closed with the 3-0 Vicryl
and the
skin was closed with Monocryl. Upon completion of the procedure, the
patient
had bilateral palpable dorsalis pedis and left radial pulse.
were present and scrubbed for the entire procedure.
IMPRESSION:
Successful realignment of previous Aneurx graft with right and left
iliac
extensions and successful treatment of internal iliac artery aneurysm
with
Viabahn stents. Extension of stent graft into external iliac artery
with a
13 x 10 Viabahn.
 
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