Wiki Open repair of right anterior tibial artery pseudoaneurysm using reversed right great saphenous vein interposition graft

mfournier

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Hello Everyone:

Can anyone guide me as to roughly what cpt code this should be? Looking in the "Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease cpt 35001-35152 but there is no tibial artery repair and this pt does not have occlusive disease.

Indications: The patient is a 23-year-old gentleman who suffered a stab injury to his right lower extremity about 4 to 5 weeks ago. He was evaluated at an outside facility, and it appears that he underwent primary repair of his stab wound. He presented to our hospital 2 days ago with persistent nonhealing and breakdown of the previous incision, and anecdotally reported several episodes of what appears to be arterial bleeding. He was found to be significantly anemic with a hemoglobin of 7, and underwent a blood transfusion. A CT angiogram of his right leg was performed demonstrating a large pseudoaneurysm arising from the proximal right anterior tibial artery. He was offered open repair to prevent further risk of hemorrhage.

Findings: Large pseudoaneurysm cavity, with a 15 mm defect in the medial aspect of the proximal anterior tibial artery. The right great saphenous vein appeared suitable for an autogenous conduit.

Narrative: The patient was brought into the operating theater and placed supine. Preoperative timeout was performed. After general anesthesia, a Foley catheter was placed. The right lower extremity was circumferentially prepped and draped in the usual sterile fashion. Given the proximity to the proximal anterior tibial artery, I elected to proceed with endovascular control. Using ultrasound guidance the right common femoral artery was accessed in antegrade fashion using a micro puncture kit, and a 5 French sheath placed. Using an angled taper catheter I was able to cannulate the right anterior tibial artery, and an angiogram was performed to delineate the large area of contained extravasation. I passed a V 18 wire distally, and used a 3 mm balloon, and inflated it for arterial control. The patient was then given systemic heparin.

I then made a longitudinal incision in the lateral aspect of the right leg and deepened to the soft tissue with cautery. I split the fibers of the anterior compartment and dissected down until identified the proximal anterior tibial artery. It was encircled with a vessel loop. I then extended my incision distally towards the mid part of the leg. We entered the pseudoaneurysm cavity, and evacuated the mural thrombus. With some difficulty I was able to dissect out the normal healthy appearing anterior tibial artery distal to the pseudoaneurysm cavity. Once I had proximal distal control I was able to better visualize the defect in the medial aspect of anterior tibial artery. This was clearly not amenable to primary repair. I elected to replace it with an interposition graft.

I then made a longitudinal incision on the medial aspect of the right knee and deepened into the soft tissue with the cautery. The great saphenous vein identified this location and appear to be of suitable size. It was mobilized for several centimeters proximally distally. The proximal distal ends were ligated, the vein transected and set aside in a heparin solution. I then deflated the balloon, and placed clamps proximal distal to the defect. The lacerated segment of the artery was transected and removed. The proximal and distal ends were spatulated. We brought on the saphenous vein graft onto the field, and oriented it in a reversed fashion. The proximal aspect of the vein graft was spatulated and end-to-end anastomosis was created to the proximal anterior tibial artery using running 7-0 Prolene. The vein graft was flushed, reclamped, and trimmed to length. The distal end of the vein graft was spatulated, and end-to-end anastomosis was created to the distal stump of the anterior tibial artery using running 7-0 Prolene. The distal stump of the artery was interrogated using a coronary dilator, flushing maneuvers were performed, and the anastomosis completed and noted to be hemostatic. There is a palpable pulse throughout the short segment of vein graft as well as in the native artery distal to this.

I then performed a completion angiogram through the sheath in the right common femoral artery demonstrating what appeared to be a patent proximal distal anastomosis with significant vasospasm proximally as well as distally beyond the anastomosis. I then crossed the bypass graft using my V 18 wire again, and brought in a 3 mm balloon to perform balloon angioplasty. After deflating it, I shot a completion angiogram once again demonstrating better flow proximally, but significant vasospasm the long segment stenosis just distal to the angioplasty site. I again advanced my balloon somewhat further distally and reinflated it again. I suspected his young age made him particularly susceptible to vasospasm with the extensive dissection necessary. Repeat angiography continued demonstrate significant vasospasm throughout the artery particularly distal to this. There is reconstitution of the distal anterior tibial artery into the dorsalis pedis artery. At this point elected to observe this for the time being. All wires and catheters were removed, and the sheath flushed with heparinized saline.

The fascia overlying the right anterior compartment was reapproximated using running 3-0 Vicryl. The skin was closed with staples. The medial knee incision was closed with 3-0 Vicryl and skin clips. The wound overlying the anterior aspect of the right leg was packed with iodoform gauze. The right femoral sheath was removed, and Angio-Seal device was used for hemostasis.

Thanks in advance
MF
 
I agree with Dianna. Report unlisted code 37799 and compare to the most distal vessel repair code available in this case would be for the popliteals 35151.
This was absolutely a direct repair of pseudoaneurysm with placement of a Saphenous vein interposition graft (I.E end to side anastomosis after excision of the aneurysmal portion of artery and placement of the saph IP graft to replace the excised portion of the artery) The associoated occlusive disease portion I am pretty sure can be with or without If I am not mistaken. ThePSA or Aneurysm drive the coding in these cases, whether or they have comorbidities consistent with occlusive disease is either or, from my understanding. I would use these codes for vessel repairs direct and open whenever there is a pseudoaneurysm or aneurysm on the table.(Aside from Endovascular embolization procedure) These codes, just like the regular vessel repair codes (35201-35286) bundle any graft technique whether it be bypass, PTFE, Dacron, Interposition graft with autogenous vgein or non-autogenous synthetic tube graft, patch angioplasty or direct repair with drainage of the PSA and suture technique. I agree that they need to expand on this code series and create codes for the tibials, and Aorto involving the femorals.
I coded a similar case this week to the one you have here, only the one I coded was an aortobifemoral bypass that was initially being done for Bilateral lower extremity claudication due to atherosclerosis with total occlusion of the right external iliac and the left common iliac. Upon preop work up my surgeon discovered a 3.5 CM suprarenal aortic aneurysm, thus she switched tehcniques and still did an aortobifemoral bypass but she technique changed, as she clamped the aorta proximal and distal to the aneurysm sac, performed a logitudinal aortotomy and open the drained the mural thrombus, removed the occlusion from the IMA ostium sutured the proximal anastomosis of the aortic graft to the inside of the aortic intima and then did a side to side anastomosis of the aortic graft and closed the sac over the aortic graft, she tunneled the limbs bilaterally to both commons right where the distal EIA's become the proximal CFA's and she did end to side anastomoses of both graft limbs.
I ended up coding my case with 35102-50, as opposed to 35646. When an aneurysm or PSA is on the table everything else becomes secondary with open repair procedures, or so it appears. In most cases. As thiis code series bundles endarterectomy and bypass grafts intpo the codes. Thats why their RVU's are so high.

Erik Brown,CIRCC,CPC.
 
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What are the differences between 35875 thrombectomy of graft w/o revision and 35876? What constitutes a revision?
If they perform a revision to improve function, such as making an incision in the graft to take out the thrombus and then inserting a patch graft, that would be 35876. If they just suture the graft closed after the thrombectomy, that would be 35875.
 
Thanks what if they thrombectomize an aortobifemoral bypass graft left limb and across the fem fem and do not place a patch or anything like that and then after thrombectomy of graft they do a new PTFE bypass from the iliac side of the left limb and tunnel it to profunda and make new arteriotomy on profunda and do anastomosis end to proximal from existing and distal anastomosis to profunda. I coded it 35875 and 35665?
also I have another 3 day absolute blockbuster of a case (headache )first day ax bi fem graft placement w/PTFE -35654.
Second day patient returned to OR for Revision thrombectomy of ax bi fem bypass graft both limbs and crossover fem to fem thrombectomized , new anastomoses placed and old graft material removed-35876-78
3rd Day. Patient had extensive thrombus and plaque all over - Procedure involved 4 Incisions . 3/4 incisions were Thromboendarterectomies. 1 SFA. 2 PFA. 1 3rd order branch of profunda incised with only thrombus removal.
1- SFA thromboendarterectomy with Seperate incision of SFA with removal of plaque and thrombus and closure with bovine. -35302-78.
2- Seperate incision and plaque/Thrombus removal of main branch of PFA with bovine closure. 3- Seperate incision of 2nd order profunda branch with plaque and thrombus removal with bovine closure. (35372-22-78-XS-RT)
4-And then patient had thrombus only that was in an additional 3rd order PFA branch that was incised and thrombectomized -34201-78-XS-RT?

the provider documented the extensive additional work and time involved in the profunda portion. I went with a 22 additionally to the 35372 as there are no add on codes for additional branch incisions and removal like the tibials do.
 
Thanks what if they thrombectomize an aortobifemoral bypass graft left limb and across the fem fem and do not place a patch or anything like that and then after thrombectomy of graft they do a new PTFE bypass from the iliac side of the left limb and tunnel it to profunda and make new arteriotomy on profunda and do anastomosis end to proximal from existing and distal anastomosis to profunda. I coded it 35875 and 35665?
also I have another 3 day absolute blockbuster of a case (headache )first day ax bi fem graft placement w/PTFE -35654.
Second day patient returned to OR for Revision thrombectomy of ax bi fem bypass graft both limbs and crossover fem to fem thrombectomized , new anastomoses placed and old graft material removed-35876-78
3rd Day. Patient had extensive thrombus and plaque all over - Procedure involved 4 Incisions . 3/4 incisions were Thromboendarterectomies. 1 SFA. 2 PFA. 1 3rd order branch of profunda incised with only thrombus removal.
1- SFA thromboendarterectomy with Seperate incision of SFA with removal of plaque and thrombus and closure with bovine. -35302-78.
2- Seperate incision and plaque/Thrombus removal of main branch of PFA with bovine closure. 3- Seperate incision of 2nd order profunda branch with plaque and thrombus removal with bovine closure. (35372-22-78-XS-RT)
4-And then patient had thrombus only that was in an additional 3rd order PFA branch that was incised and thrombectomized -34201-78-XS-RT?

the provider documented the extensive additional work and time involved in the profunda portion. I went with a 22 additionally to the 35372 as there are no add on codes for additional branch incisions and removal like the tibials do.
I'd suggest adding this question in a new post and see if anyone else can help. I'm still reviewing though. From the looks of your question, you get the same kind of mind blowing cases I look at every day.
 
All good I apologize, shouldn’t be dumping all of that on yourself or others. I re reviewed all of them and stick to my guns and our auditors approved it. I appreciate your help. It’s always good to discuss tough cases with other professionals ! Enjoy and have a safe and good weekend.
 
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