Question Need help with patch arterioplasty, stent, thrombectomy

luvmyphx

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Need advice on coding these procedures:


PROCEDURES: 1) R CFA/EIA/PFA/SFA exploration 2) patch arterioplasty R EIA and R CFA 3) thrombectomy of PFA 4) balloon angioplasty 4 x 30mm Evercross 5) balloon-expandable stent R EIA (overlapping prior distal end of R EIA iCast) 6) aortogram and bilateral runoff

After satisfactory placement patient supine on the operative table in the hybrid room with all surfaces carefully padded and protected, with a good level of general anesthesia the patient’s abdomen, right leg circumferentially to the toes, left leg anteriorly to the level of the knee were all prepped and draped in sterile fashion in contiguity. Her previous vertical right groin incision was reopened and extended distally. With a goal of dissecting down to a previously unexplored superficial femoral artery we accomplish this and then followed the artery to the groin. There was very severe cicatrix involving the entire common, profunda and superficial femoral arteries in the previous area of operative manipulations. This required an extra 1 hour of dissection time to carefully expose the common femoral artery and its branches, in particular the profunda femoris which was paper-thin and constitutes the only outflow tract of the common femoral system feeding the right leg. This dissection difficulty called flies this procedure for a 22 modifier.

The patient was systemically heparinized. Subsequent ACT was maintained in the therapeutic range and heparin was supplemented as needed.

Once the heparin was circulated the very distal external iliac artery was controlled with a vascular clamp. Potts loops of Silastic were used to control the medial profunda branch and the profunda femoris itself laterally. The SFA itself was known to be occluded at its orifice.

REDO ENDARTERECTOMY AND PATCH ARTERIOPLASTY  The common femoral artery was covered with a thick cicatrix in linear fashion from the distal external iliac artery to the superficial femoral artery and this scar was dissected away. The previously placed patch was found to be indurated and covered with scar. Extensive retraction by the assistant via the inguinal ligament was was required in order to carry the dissection approximately 4 cm onto the distal external iliac artery, at which point the previously placed stent-graft was palpable. This was marked so as to preclude clamping at that site.  The profunda femoris and a separate medial profunda femoris branch, and the SFA (occluded) were prepared for control Silastic loops of Potts configuration.
Using an 11 blade at a location on the common femoral artery which appeared to have flow by Doppler we incised this in longitudinal fashion and opened the artery to the level of the distal external iliac artery with Potts scissors. The artery was then opened onto the superficial femoral artery for several centimeters to assess its patency. The SFA was patent to gentle probing but was functionally occluded and based on this exploration and CTA findings there was no opportunity to recanalize this vessel which is occluded all the way to the popliteal artery at which point the popliteal artery is only 2.5 mm in diameter. At the segment of our exploration we found full obliteration of the SFA lumen.
Attention was turned to the external iliac artery. Obvious plaque proximal to the clamp was encountered, and it was clear that we needed to control the external iliac artery more proximally and this could not be accomplished with a clamp because of the presence of the stent. Therefore a 6 mm x 40 mm Mustang angioplasty balloon was passed into the mid-zone of the external iliac artery stent and inflated just enough to control blood flow antegrade. This was effective control. Control of the profunda femoris and medial profunda branch was continued with Potts loops applied gently. The distal external iliac artery was then carefully endarterectomized. The plaque here appeared to be very active. Endarterectomy was made more difficult because of the adherence of this tissue but was accomplished. Endarterectomy was then carried out of extensive sentinel intimal hyperplasia involving the area of the previously placed patch arterioplasty. This was carried down 2 centimeters beyond the level of the profunda femoris orifice laterally. We then oversewed the longitudinal arteriotomy which had been extended into the SFA beyond, as not to include the nonfunctional SFA in our arterioplasty patch.he endarterectomy bed looked quite good. A bovine pericardial patch measuring 18 mm wide by approximately 8 cm length was fashioned. This was then sutured to the arteriotomy using running 5-0 Prolene. Prior to placing the final sutures the system was flushed and de-aired, the final sutures were taken and tied and flow was opened retrograde then antegrade. Several patch sutures were required at the edge of the arterioplasty medially and superiorly.

COMPLETION ANGIOGRAPHY & STENTING
Although flow by Doppler was good into the patch at this point completion angiography was indicated. The past portion of the patch was identified and a pursestring suture was placed wide enough for insertion of a sheath. The imaging system was brought into position. 18-gauge needle was used to puncture within the pursestring and an 035 angled Glidewire was placed to the aorta under fluoroscopic guidance. A 4 French sheath was placed.
Angiography disclosed a narrowing just beyond the distal most portion of the previously placed stent-graft. This did not improve on repeat injection and was clearly related to anatomic narrowing and not clamp affect.
The 4 French sheath was upsized to 6 French. Measurements were taken. A VISI-PRO balloon- expandable stent measuring 7 mm x 27 mm was chosen.
Pre-dilatation was then carried out. An Evercross 4 mm x 40 mm balloon was passed to the stenosis and inflated for 1 minute. This was deflated and removed. The VISI-PRO balloon-expandable 7 x 27 mm stent was then passed to this area, 12 mm of overlap allowed, and this was inflated for 1 minute. Stent balloon was deflated and removed.
Final angiography disclosed full effacement of the stenosis and good stent position, with good runoff into the profunda femoris channel which along with iliac collaterals provides for her entire lower extremity perfusion. The sheath was pulled via the pursestring which was tied. Doppler signals remained excellent.

Hemostasis was obtained. Doppler signals from the level of the external iliac artery through the patch segment and including the accessible areas of the profunda femoris were excellent. Compared to the pre-revascularization signals the signals were rather torrential. Copious irrigation with antibiotic and saline was carried out of the right groin wound. After final careful check for hemostasis which was excellent, the incision was closed in layers with 2-0 absorbable Vicryl in the deep layer, 30 absorbable Vicryl in the superficial fat layer, and a running 4-0 subcuticular stitch in the skin. Steri-Strips and sterile dressings were applied. The patient was awakened, transported to the postprocedure area in stable condition having tolerated the procedure well.

Thank you!!!
 
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