Hi, I am a bit confused on this and was wondering if this was an axillary-femoral bypass, 35621-RT or was this a fem-axillary bypass. According to the operative procedure, the physician states she performed a right femoral to right axillary bypass PTFE. However, may be I am reading to much into this and think that was more of an axillary-femoral bypass. If it is a fem-axillary bypass, would I use an unlisted code of 37799? Any feedback would be appreciated. Thank you!
DETAILS OF OPERATION: The patient was brought to the operating room and place in supine position in the operating room table. Anesthesia was induced and patient was intubated. Antibiotic was infused, a Foley catheter was placed by nursing staff. A time out was completed. The right arm, chest, abdomen and bilateral legs were prepped and draped in sterile fashion. A transverse incision was made 1 fingerbreadth below the left clavicle in its distal portion, about 5 cm in length. The skin and subcutaneous tissue were dissected with cautery and the pectoralis major muscle fibers were split, exposing the fat containing the axillary artery and vein and their branches. The artery was dissected free of the surrounding tissues, no arterial branches were ligated. A venous branch crossing the artery was ligated and divided to allow better exposure of the artery.
Next, a longitudinal incision was created along the right groin. The inguinal ligament and femoral arterial complex was identified and loop controlled. There was a soft spot in the proximal common femoral artery and there was plaque in the posterior femoral artery.
A subcutaneous tunnel was created between the right groin and the right axillary artery. A tunneler was passed above the inguinal ligament towards the mid axillary line. A transverse skin incision was made in the mid portion of the mid axillary line to help tunneling. The tunneler was then passed posterior to the pectoralis minor muscle. A 6 mm externally supported, thin Gore graft was passed through the tubular tunneler taking care no to twist during passage. Therapeutic heparin bolus was administered. Three minutes later, the common femoral, profunda and superficial femoral arteries were clamped and the graft was anastomosed to the femoral arteries in an end-side fashion with 5-0 Prolene. The arteries were flushed prior to completing the anastomosis. The axillary artery was clamped. A longitudinal arteriotomy was created in the axillary artery and extended with Potts scissors. The axillary end of the graft was spatulated and an end-to-side graft to axillary artery anastomosis was created using running 5-0 Prolene. Some redundancy of the graft in the axilla was left to reduce the risk of axillary pullout. Doppler insonation after unclamping the graft showed strong biphasic signals in common femoral, PFA and SFAs, axillary artery and right radial artery. Hemostasis was achieved with a combination of electrocautery and Surgicel. The wounds were irrigated. After confirming hemostasis, the major pectoralis muscle was approximated with 2-0 Vicryl and deep tissue closed with 3-0 Vicryl and skin approximated with 3-0 Nylon with mattress sutures. The right groin was irrigated, hemostasis confirmed and closed with 2-0 and 3-0 Vicryl in running fashion and the skin was approximated with 3-0 Nylon with mattress sutures. Sterile dressings were applied.
Then, the right neck wound was irrigated and hemostasis confirmed. There was no necrotic tissue and the wound bed was pink with granulation tissue. A white sponge, black sponge were applied and secured with VAC tape with adequate seal. The patient had a right radial signal and a palpable right PT pulse at the end of the case. All counts were correct. The patient was awakened from anesthesia and transported to the recovery room in stable condition.
Grafts and Implants
6 mm PTFE graft
DETAILS OF OPERATION: The patient was brought to the operating room and place in supine position in the operating room table. Anesthesia was induced and patient was intubated. Antibiotic was infused, a Foley catheter was placed by nursing staff. A time out was completed. The right arm, chest, abdomen and bilateral legs were prepped and draped in sterile fashion. A transverse incision was made 1 fingerbreadth below the left clavicle in its distal portion, about 5 cm in length. The skin and subcutaneous tissue were dissected with cautery and the pectoralis major muscle fibers were split, exposing the fat containing the axillary artery and vein and their branches. The artery was dissected free of the surrounding tissues, no arterial branches were ligated. A venous branch crossing the artery was ligated and divided to allow better exposure of the artery.
Next, a longitudinal incision was created along the right groin. The inguinal ligament and femoral arterial complex was identified and loop controlled. There was a soft spot in the proximal common femoral artery and there was plaque in the posterior femoral artery.
A subcutaneous tunnel was created between the right groin and the right axillary artery. A tunneler was passed above the inguinal ligament towards the mid axillary line. A transverse skin incision was made in the mid portion of the mid axillary line to help tunneling. The tunneler was then passed posterior to the pectoralis minor muscle. A 6 mm externally supported, thin Gore graft was passed through the tubular tunneler taking care no to twist during passage. Therapeutic heparin bolus was administered. Three minutes later, the common femoral, profunda and superficial femoral arteries were clamped and the graft was anastomosed to the femoral arteries in an end-side fashion with 5-0 Prolene. The arteries were flushed prior to completing the anastomosis. The axillary artery was clamped. A longitudinal arteriotomy was created in the axillary artery and extended with Potts scissors. The axillary end of the graft was spatulated and an end-to-side graft to axillary artery anastomosis was created using running 5-0 Prolene. Some redundancy of the graft in the axilla was left to reduce the risk of axillary pullout. Doppler insonation after unclamping the graft showed strong biphasic signals in common femoral, PFA and SFAs, axillary artery and right radial artery. Hemostasis was achieved with a combination of electrocautery and Surgicel. The wounds were irrigated. After confirming hemostasis, the major pectoralis muscle was approximated with 2-0 Vicryl and deep tissue closed with 3-0 Vicryl and skin approximated with 3-0 Nylon with mattress sutures. The right groin was irrigated, hemostasis confirmed and closed with 2-0 and 3-0 Vicryl in running fashion and the skin was approximated with 3-0 Nylon with mattress sutures. Sterile dressings were applied.
Then, the right neck wound was irrigated and hemostasis confirmed. There was no necrotic tissue and the wound bed was pink with granulation tissue. A white sponge, black sponge were applied and secured with VAC tape with adequate seal. The patient had a right radial signal and a palpable right PT pulse at the end of the case. All counts were correct. The patient was awakened from anesthesia and transported to the recovery room in stable condition.
Grafts and Implants
6 mm PTFE graft