Wiki need a 2nd opinion for a parallel graft

deeva456

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Hi
I need a 2nd opinion on a case I am unfamiliar with. The physician did a parallel graft in the popliteal artery. I came up with 35152 and possibly adding modifier 22. Is there another code we should bill for?

I appreciate any feedback. Thank you


PROCEDURE PERFORMED:
Repair of left popliteal vein aneurysm with resection and interposition graft
placement, using left saphenous vein parallel panel graft, posterior
approach.

ANESTHESIA TYPE:
General anesthesia with regional anesthesia.

INDICATIONS FOR PROCEDURE:
She has a history of a left popliteal
vein aneurysm that was initially repaired in 2008, however, over time
recurred, now with aneurysm of 3 cm and on the latest imaging, began to have
peripheral thrombus forming. She was placed on Eliquis and scheduled for
surgery to prevent deep vein thrombosis formation as well as local congestive
type symptoms. Risks, benefits, and alternatives were discussed with the
patient regarding the procedure and she did agree to proceed with the
intervention.

DETAILS OF THE PROCEDURE:
The patient was brought to the operating room and placed in supine position
on the operating room table. She had regional blocks placed by Dr. XYZ. She
was placed under general anesthesia. She was then initially placed in supine
position where she was prepped and draped to expose the left lower extremity
circumferentially. The saphenous vein was evaluated and its location was
marked prior to prepping the leg. Of note, she did receive vancomycin for
perioperative antibiotic coverage, which was given 1 hour prior to the
incision. We began by harvesting the saphenous vein from the proximal medial
thigh through 3 skip incisions. The branches were divided with silk ties and
hemoclips. We harvested a total segment of 20 cm of saphenous vein. The
saphenous vein from its proximal aspect was divided and a stick tie was
placed onto the saphenofemoral junction to occlude the saphenous vein
proximally. Distally, a silk tie was placed around the distal end. The
saphenous vein was dilated with heparinized saline and then set aside. The
wounds were irrigated with Ancef irrigation and then the wounds were closed
in 2 layers with a deep dermal layer using 2-0 Vicryl and the skin was closed
with a 4-0 Monocryl in a running fashion. At the medial calf, there was area
of bulging veins from the saphenous vein that were removed through 2 small
stab incisions. The thigh incisions were covered with Exofin skin glue. The
calf small incisions were covered with Steri-Strips. The draping was then
taken down. The patient was then repositioned, maintaining general
anesthesia so that she was now prone on the surgical table. This was done so
by a brief transfer to a gurney. Now, in the prone position, she was
re-prepped and draped to expose the left lower extremity up to the posterior
thigh. We now proceeded with the aneurysm portion. I did mark the location
of her previous scar, which was across the popliteal fossa. I did utilize
the medial portion of that scar by placing my incision there. I did do a
lazy Z-type incision with the incision extending proximally on the medial
aspect and distally on the lateral aspect of the incision. We divided the
skin with a 15 blade and then dissected through the deep dermis. After small
amount of dissection, we did quickly identify the popliteal venous aneurysm
protruding in the back of the popliteal fossa. I cleared the tissue over the
aneurysm until I was able to identify the popliteal vein entering the
aneurysm, which was of normal caliber. I was able to place a vessel loop
around this. I then continued the dissection distally until I was able to
identify the distal outflow vein. A vessel loop was placed around this.
During the dissection, I did proceed with heparinization. The patient was
given 4000 units of intravenous heparin. We did take care not to cause any
injury or traction necessarily to the accompanying popliteal vein or the
nerves. At this point, vascular clamps were placed onto the popliteal vein
above and below the aneurysm. I then entered the aneurysm sac and
encountered a significant amount of backbleeding from large branches that
were not identified initially. Ultimately, these branches did get ligated.
In the process of dissection, I also did identify the old aneurysm repair
sutures toward the proximal aspect of the aneurysm. Once we did have control
of the branches and control of the bleeding, we proceeded with
reconstruction. However, prior to opening the aneurysm up, I had created a
parallel graft. I used the saphenous vein that had been previously
harvested. It was cut into 3 sections that were about 5-6 cm in length. Each
segment of vein was opened longitudinally to create a panel. These panels
were then sewn together. First, the 2 panels were sewn together using 7-0
Prolene. The panels were sewn together in a longitudinal fashion. We
wrapped the panels around a 24-French chest tube. The chest tube's outer
diameter measured about 8 mm in diameter. When we placed the 2 panels onto
the chest tube, it was not quite large enough and so I decided to sew on a
3rd panel again in a parallel fashion. The 3rd panel it opened in a similar
fashion and that 3rd segment was sewn on its longitudinal aspect to make a
larger diameter vein. Now, we wrapped the 3 panels around the 24-French
chest tube and saw that it was a good size match. Now, the final site was
sewn together using again 7-0 Prolene over the chest tube. The panel graft
was now completed and this same graft was used to anastomose in an end-to-end
fashion to the proximal popliteal vein. The anastomosis was performed with a
6-0 Prolene. After completion of the proximal anastomosis, I did place a
padded vascular clamp onto my parallel graft and allowed blood flow into the
parallel graft. There was one area that required a repair suture. I then
proceeded to do the distal anastomosis in an end-to-end fashion again using a
6-0 Prolene. Before completing the anastomosis, we did forward bleed and
back bleed the popliteal vein. Anastomosis was completed and flow was
restored into the popliteal vein. We used Doppler to Listen to the flow the vein, which
had good flow and good augmentation with distal squeezing of the calf.
Hemostasis was achieved. I did utilize Surgicel and Floseal. The wound was
irrigated with Ancef irrigation and then ready for closure. Now for closure,
the fascial layer and deep dermal layers were approximated with 2-0 PDS in an
interrupted fashion. The skin was then closed with a 4-0 Monocryl in a
running fashion. Exofin was placed onto the skin edges. The drapes were
taken down and she was flipped supine. Now in the supine position, her leg
was wrapped with 4 x 4's over the incisions as well as an ABD at the
posterior knee and Kerlix and Ace wrap from the foot to the thigh. A knee
immobilizer was then applied to the left lower extremity to prevent bending
at the knee. The patient was then awakened from anesthesia and transferred
to recovery in stable condition without any identified complications.
 
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