Hello,
I have been struggling with this OP report for days. I'm not sure if I have the right codes or not. The codes I came up with are 27602, 37228, 75710, 37226, 34201, and 76937.
Any assistance would be greatly appreciated. Thanks in advance!!
PREOPERATIVE DIAGNOSIS: ACUTE LIMB ISCHEMIA.
POSTOPERATIVE DIAGNOSIS: ACUTE LIMB ISCHEMIA WITH MOTOR AND SENSORY
LOSS.
OPERATION:
1. COMMON FEMORAL ARTERY FEMORAL CUTDOWN.
2. SUPERFICIAL FEMORAL ARTERY EMBOLECTOMY WITH A #3 AND #4 FOGARTY.
3. BELOW KNEE POPLITEAL ARTERY CUTDOWN WITH EMBOLECTOMY OF THE
POPLITEAL AND SUPERFICIAL FEMORAL ARTERY #3 FOGARTY.
4. DIAGNOSTIC ANGIOGRAM OF THE RIGHT LOWER EXTREMITY.
5. PLACEMENT OF VBX STENT IN THE SUPERFICIAL FEMORAL ARTERY (6 BY 10, 8
BY 10, 8 BY 10).
6. PATCH ANGIOPLASTY OF THE TIBIOPERONEAL TRUNK.
7. FOUR COMPARTMENT FASCIOTOMY OF THE RIGHT LOWER EXTREMITY.
ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.
PROCEDURE:
The patient was brought to the Operating Room and placed supine on the
operating room table. Time-out was performed verifying the correct
patient, procedure and all available equipment in the room. The patient
underwent general anesthesia and endotracheal intubation. Foley
catheter was placed in the radial arterial line.
The right leg was circumferentially prepped and draped in the sterile
fashion over to the left groin. The common femoral artery was marked
under ultrasound as well as the bifurcation. The 15 blade was used to
make a longitudinal incision in the right groin.
Using blunt and electrocautery the common femoral artery was identified,
circumferentially dissected. Proximal and distal control was gained
using yellow vessel loops. All branches of the common femoral artery
were also obtained with blue silastic vessel loops. Profunda was
circumferentially dissected also controlled with yellow silastic vessel
loops.
A transverse arteriotomy was then created with an 11 blade. There was
evidence of thrombus within the common femoral artery. The vein was
extracted. Proximal inflow from the external iliac was brisk and had no
evidence of thrombus.
Using a #4 Fogarty it was passed distally into the superficial femoral
artery multiple times with return of thrombus, however, no evidence of
adequate backbleeding. A #3 Fogarty was also used with the return of
thrombus and backbleeding. The profunda femoral artery had good
backbleeding. Due to the concern that there are copious amounts of
thrombus throughout the knee arterial system, a below knee excision was
then performed.
At the level of the medial malleolus a skin incision was made in the
medial aspect of the below knee along the length of the tibia
approximately 10 cm. The superficial posterior ______ was entered and
the soleus was taken off the tibia.
The popliteal fossa was then entered and the popliteal artery as well as
the tibioperoneal trunk, the PT and peroneal were identified using sharp
dissection and circumferentially dissected. Vessel loops were used to
control these arteries. The condition of the tibioperoneal had evidence
of extensive atherosclerotic disease.
A transverse arteriotomy was made over the tibioperoneal trunk using a
#3 Fogarty balloon passed proximally. Thrombus was extracted from the
below knee popliteal artery to the SFA with moderate forward bleeding.
A coronary dilator was attempted to be passed into the peroneal artery
but no identifiable lumen was identified. Posterior tibial artery clear
limb could not be identified and could not be passed to the Fogarty
balloon.
Decision was then made to perform a diagnostic angiogram of the right
lower extremity to identify the condition of the anterior tibial artery
as this was not easily visualized. A micropuncture artery was used to
gain access to the common femoral artery and inserted into the
cerebrovascular accident using micropuncture wire. Micropuncture sheath
was inserted. It was exchanged for a 5-French sheath over a J-wire.
A diagnostic angiogram was then performed showing extensive thrombus
still persistent within the superficial femoral artery as well as the
below knee popliteal artery. Anterior tibial artery had no flow and
appeared to be occluded. The sheath was retracted and the common
femoral artery was clamped and a retrograde angiogram was done to show
the profunda femoral artery. The profunda femoral artery had evidence
of extensive disease in the distal collaterals but no apparent thrombi.
The decision was made to attempt to cross the anterior tibial artery and
improve a better picture. The 0.018 Glidewire Advantage was inserted
down into the tibioperoneal trunk over a Quick-Cross catheter. The
orifice to the anterior tibial artery was inserted with the Glidewire
Advantage and it appeared to be completely occluded with no
reconstitution of flow.
At this time, it was decided to place cover stents within the
superficial femoral artery in the areas of recurrent thrombosis.
Distally using 6 by 10 VBX stent times one extending from the below knee
popliteal artery up into the above knee popliteal artery and then an 8
by 10 stent from the above knee popliteal artery SFA times two extending
to the area of resistant thrombus. Post angiographic results were
excellent flow up into the level of the tibioperoneal trunk.
At the completion of this, a three brain suture was placed at the common
femoral artery arteriotomy where the sheath was and the sheath was then
removed. Of note, during the entire case ACT was checked and the
patient was systemically heparinized throughout the portion of the case.
The tibioperoneal trunk then had excellent forward bleeding from the
superficial femoral artery and below knee popliteal artery and at this
time there was evidence of backbleeding from the posterior tibial
artery. The arteriotomy was extended longitudinally along the length of
the posterior tibial artery to identify the lumen.
Then a patch angioplasty was done extending from the posterior tibial
onto the tibioperoneal trunk using XenoSure biologic patch. The
peroneal artery had no evidence of backbleeding and was transected to
identify lumen ______ onto the angioplasty of the tibioperoneal trunk
but there was no evidence of lumen and it was consistent with the
chronic occlusion. The peroneal artery was then ligated with the 3-0
silk tie.
Prior to completion of the anastomosis with a patch, the artery was
allowed to forward and back bleed. Hemostasis was achieved with
Gelfoam, thrombin. Of note, the superficial posterior compartment was
opened during the dissection as well as the deep posterior compartment
was opened during the dissection.
Next, on the lateral aspect of the knee four fingerbreadths below the
lateral malleolus along the length of the fibula a skin incision was
made and the anterior and lateral compartments were then opened to
complete a four compartment fasciotomy. There was no evidence of
bulging without the muscles. The skin was then closed with staples.
After completion of the patch angioplasty, Doppler was used and there
was excellent triphasic signal both proximal and distal to the patch in
the posterior tibial artery and tibioperoneal trunk.
Hemostasis was achieved in both the below knee pop as well as the common
femoral artery incision with Gelfoam and thrombin and electrocautery.
The below knee incision was closed with deep dermal 3-0 Vicryl running
and skin staples. The common femoral artery incision was closed with
interrupted 2-0 Vicryls, the femoral sheath 2-0 Vicryls and the
subcutaneous fascia and 3-0 Vicryls along the deep dermal and 4-0
Monocryl for the skin. Dermabond was placed on the skin. An airplane
dressing was placed on both the leg incisions.
At the completion of the case, the patient did not have a Doppler PT
signal. The patient was extubated and brought to the CSICU in stable
condition.
I have been struggling with this OP report for days. I'm not sure if I have the right codes or not. The codes I came up with are 27602, 37228, 75710, 37226, 34201, and 76937.
Any assistance would be greatly appreciated. Thanks in advance!!
PREOPERATIVE DIAGNOSIS: ACUTE LIMB ISCHEMIA.
POSTOPERATIVE DIAGNOSIS: ACUTE LIMB ISCHEMIA WITH MOTOR AND SENSORY
LOSS.
OPERATION:
1. COMMON FEMORAL ARTERY FEMORAL CUTDOWN.
2. SUPERFICIAL FEMORAL ARTERY EMBOLECTOMY WITH A #3 AND #4 FOGARTY.
3. BELOW KNEE POPLITEAL ARTERY CUTDOWN WITH EMBOLECTOMY OF THE
POPLITEAL AND SUPERFICIAL FEMORAL ARTERY #3 FOGARTY.
4. DIAGNOSTIC ANGIOGRAM OF THE RIGHT LOWER EXTREMITY.
5. PLACEMENT OF VBX STENT IN THE SUPERFICIAL FEMORAL ARTERY (6 BY 10, 8
BY 10, 8 BY 10).
6. PATCH ANGIOPLASTY OF THE TIBIOPERONEAL TRUNK.
7. FOUR COMPARTMENT FASCIOTOMY OF THE RIGHT LOWER EXTREMITY.
ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.
PROCEDURE:
The patient was brought to the Operating Room and placed supine on the
operating room table. Time-out was performed verifying the correct
patient, procedure and all available equipment in the room. The patient
underwent general anesthesia and endotracheal intubation. Foley
catheter was placed in the radial arterial line.
The right leg was circumferentially prepped and draped in the sterile
fashion over to the left groin. The common femoral artery was marked
under ultrasound as well as the bifurcation. The 15 blade was used to
make a longitudinal incision in the right groin.
Using blunt and electrocautery the common femoral artery was identified,
circumferentially dissected. Proximal and distal control was gained
using yellow vessel loops. All branches of the common femoral artery
were also obtained with blue silastic vessel loops. Profunda was
circumferentially dissected also controlled with yellow silastic vessel
loops.
A transverse arteriotomy was then created with an 11 blade. There was
evidence of thrombus within the common femoral artery. The vein was
extracted. Proximal inflow from the external iliac was brisk and had no
evidence of thrombus.
Using a #4 Fogarty it was passed distally into the superficial femoral
artery multiple times with return of thrombus, however, no evidence of
adequate backbleeding. A #3 Fogarty was also used with the return of
thrombus and backbleeding. The profunda femoral artery had good
backbleeding. Due to the concern that there are copious amounts of
thrombus throughout the knee arterial system, a below knee excision was
then performed.
At the level of the medial malleolus a skin incision was made in the
medial aspect of the below knee along the length of the tibia
approximately 10 cm. The superficial posterior ______ was entered and
the soleus was taken off the tibia.
The popliteal fossa was then entered and the popliteal artery as well as
the tibioperoneal trunk, the PT and peroneal were identified using sharp
dissection and circumferentially dissected. Vessel loops were used to
control these arteries. The condition of the tibioperoneal had evidence
of extensive atherosclerotic disease.
A transverse arteriotomy was made over the tibioperoneal trunk using a
#3 Fogarty balloon passed proximally. Thrombus was extracted from the
below knee popliteal artery to the SFA with moderate forward bleeding.
A coronary dilator was attempted to be passed into the peroneal artery
but no identifiable lumen was identified. Posterior tibial artery clear
limb could not be identified and could not be passed to the Fogarty
balloon.
Decision was then made to perform a diagnostic angiogram of the right
lower extremity to identify the condition of the anterior tibial artery
as this was not easily visualized. A micropuncture artery was used to
gain access to the common femoral artery and inserted into the
cerebrovascular accident using micropuncture wire. Micropuncture sheath
was inserted. It was exchanged for a 5-French sheath over a J-wire.
A diagnostic angiogram was then performed showing extensive thrombus
still persistent within the superficial femoral artery as well as the
below knee popliteal artery. Anterior tibial artery had no flow and
appeared to be occluded. The sheath was retracted and the common
femoral artery was clamped and a retrograde angiogram was done to show
the profunda femoral artery. The profunda femoral artery had evidence
of extensive disease in the distal collaterals but no apparent thrombi.
The decision was made to attempt to cross the anterior tibial artery and
improve a better picture. The 0.018 Glidewire Advantage was inserted
down into the tibioperoneal trunk over a Quick-Cross catheter. The
orifice to the anterior tibial artery was inserted with the Glidewire
Advantage and it appeared to be completely occluded with no
reconstitution of flow.
At this time, it was decided to place cover stents within the
superficial femoral artery in the areas of recurrent thrombosis.
Distally using 6 by 10 VBX stent times one extending from the below knee
popliteal artery up into the above knee popliteal artery and then an 8
by 10 stent from the above knee popliteal artery SFA times two extending
to the area of resistant thrombus. Post angiographic results were
excellent flow up into the level of the tibioperoneal trunk.
At the completion of this, a three brain suture was placed at the common
femoral artery arteriotomy where the sheath was and the sheath was then
removed. Of note, during the entire case ACT was checked and the
patient was systemically heparinized throughout the portion of the case.
The tibioperoneal trunk then had excellent forward bleeding from the
superficial femoral artery and below knee popliteal artery and at this
time there was evidence of backbleeding from the posterior tibial
artery. The arteriotomy was extended longitudinally along the length of
the posterior tibial artery to identify the lumen.
Then a patch angioplasty was done extending from the posterior tibial
onto the tibioperoneal trunk using XenoSure biologic patch. The
peroneal artery had no evidence of backbleeding and was transected to
identify lumen ______ onto the angioplasty of the tibioperoneal trunk
but there was no evidence of lumen and it was consistent with the
chronic occlusion. The peroneal artery was then ligated with the 3-0
silk tie.
Prior to completion of the anastomosis with a patch, the artery was
allowed to forward and back bleed. Hemostasis was achieved with
Gelfoam, thrombin. Of note, the superficial posterior compartment was
opened during the dissection as well as the deep posterior compartment
was opened during the dissection.
Next, on the lateral aspect of the knee four fingerbreadths below the
lateral malleolus along the length of the fibula a skin incision was
made and the anterior and lateral compartments were then opened to
complete a four compartment fasciotomy. There was no evidence of
bulging without the muscles. The skin was then closed with staples.
After completion of the patch angioplasty, Doppler was used and there
was excellent triphasic signal both proximal and distal to the patch in
the posterior tibial artery and tibioperoneal trunk.
Hemostasis was achieved in both the below knee pop as well as the common
femoral artery incision with Gelfoam and thrombin and electrocautery.
The below knee incision was closed with deep dermal 3-0 Vicryl running
and skin staples. The common femoral artery incision was closed with
interrupted 2-0 Vicryls, the femoral sheath 2-0 Vicryls and the
subcutaneous fascia and 3-0 Vicryls along the deep dermal and 4-0
Monocryl for the skin. Dermabond was placed on the skin. An airplane
dressing was placed on both the leg incisions.
At the completion of the case, the patient did not have a Doppler PT
signal. The patient was extubated and brought to the CSICU in stable
condition.