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Removal/replacement of a partial fem/pop bypass graft

deeva456

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Hello.

I need some help in coding a partial removal/replacement of femoral to below-knee popliteal bypass graft with cryovein. The codes I have so far are 35903 & 35883 but it doesn't quite describe the work that was done. Also will code for wound vac.

Your help is greatly appreciated!!


PROCEDURE:
1. Right leg wound debridement, right groin and right lower leg.
2. Partial removal of right femoral to below-knee popliteal bypass from the
proximal anastomosis down.
3. Replacement of the portion of the right femoral to below-knee popliteal
bypass with a segment of cryovein.

DETAILS OF PROCEDURE: The patient is a 67-year-old male with multiple
comorbidities who is status post right femoral to below-knee popliteal bypass
with PTFE done 2 weeks ago. The patient is also status post previous
aortobifemoral and failed right fem-pop bypass done in 2001 and 2002.
Following the most recent surgery the patient developed significant swelling
of the right lower extremity and dehisced both his incisions with the graft
being exposed at the right groin incision. After signing consent, during
which risks and benefits of the procedure were discussed and described in
detail, the patient was brought into the Operating Room, placed on the
operating table in supine position. The right lower extremity was prepped and
draped in the usual sterile fashion. Both wounds were exposed and examined.
Necrotic debris was removed and submitted for microbiological evaluation.
Total of 3 liters of antibiotic irrigation was used to irrigate both incisions
using Pulsavac irrigation system. Next, instruments were changed and lower
leg wound was examined. It appeared to be dehisced only at the superficial
level. Remainder of the graft and the bypass appeared to be very well
incorporated without any gross purulence. At this point, the decision was
made to leave that portion of the graft attached. Wound was partially closed
with several interrupted deep dermal inverted stitches using 2-0 Vicryl and
several vertical mattress stitches using 2-0 nylon. White sponge was used to
pack the small tunnel at the lower wound and the silver sponge was placed on
top. It was connected to the wound VAC. Next, the proximal incision was
examined. As mentioned before, necrotic debris was removed and the wound was
thoroughly irrigated with the Pulsavac irrigation system. Graft, as I
mentioned before, was exposed. Aortobifemoral appeared to be well
incorporated. No gross purulence was encountered besides the necrotic tissue
of hematoma and remaining from previous surgery FloSeal and Surgicel. All
that was removed. The patient received 6000 units of heparin. Proximal and
distal control was obtained using vascular clamps and the proximal portion of
the graft was removed from the common femoral artery patch to which it was
anastomosed previously. Common femoral artery was irrigated. There was good
backbleeding noted through the profunda femoris artery and through the graft.
Graft was flushed with heparinized saline.

The carotid vein was prepared according to manufacturer's specifications. A
segment of the vein was brought into the wound, the end of it was spatulated
and the vein was then anastomosed to the common femoral artery. Next, a
segment of the graft was dissected down to the point where the graft appeared
to be well incorporated into the tissue. Incision was extended in order to
get to the part where the graft appeared to be well incorporated and not
previously exposed. The graft was cut in oblique fashion and reanastomosed to
the vein in oblique fashion using 6-0 Gore-Tex suture. Prior to completion of
anastomosis the area was allowed to backbleed then forward bleed. Once
anastomosis was completed, it was examined for hemostasis. Wound was once
again thoroughly irrigated and we proceeded with mobilizing sartorius muscle.
The isthmus was mobilized and reflected medially covering the common femoral
artery and bypass. Using multiple interrupted 2-0 stitches, the muscle was
approximated to the tissue at the medial aspect of the wound. Ends of the
incisions were approximated with several interrupted mattress 2-0 nylon
sutures. Silver sponge was packed into the wound and connected to the wound
VAC. Next, signals were checked with Doppler and appeared to be unchanged
from before the beginning of the surgery. The patient tolerated the procedure
well. There were no complications.
 
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