Wiki thoracic aortic aneurysm

[rocoder]

I think this should be coded as 33864 but I don't see the coronary artery buttons being reimplanted into the graft.

I greatly appreciate your input!!

Here is the op note:

A median sternotomy performed without complication. The patient was heparinized.

The patient was cannulated with a 29 fr dual stage venous cannula and retrograde cardioplegia cannulae. The patient was placed on bypass and cooled to 18 deg cel. An LV vent was placed via the RSPV.

Coronary targets identified. The aorta was then cross clamped followed by antegrade cardioloplegia with excellent arrest (custodiol). Ostial and retrograde cardioplegia was used for maintenance during the case.

At 18 degrees, the innominate artery was gently snared (vessel loops). SACP initiated. The aorta was opened. Cardioplegia was give. The dissected and diseased aorta was resected from the STJ to the hemiarch.
The tear was at the STJ and resected there. Since the dissection went all the way to the arch vessels but the tear did not, the decision was made to do a hemiarch repair. The dissected aortic tissue was reapproximated with bioglue and felt (inside/outside). The 32mm graft was sewn to the hemiarch with running 4-O prolene.
The innominate was released. The clamp was moved the the graft. Hemostasis was achieved. Attention was turned to the root.
The tear did not extend into the root although the dissection did. The valve was resuspended with pledgeted 4-O prolene. The root was reconstructed with bioglue and felt, as well as pericardium. Incidentally, the aortic valve was quadrileaflet. The graft was sewn to the proximal aorta with running 4-O prolene.

Root vent was placed. The heart was de-aired. The clamp was removed. At first, there was hemostasis but then significant bleeding started from the proximal aortic anastomosis despited repair stitches.. There was tearing of the sutures and the fragile aortic tissue was not holding.

The heart was re-arrested and the proximal anastomosis redone. This time the root was reconstructed with felt between the layers as well as on the inside and the outside of the aorta, using judicious application of bioglue. The aorta was reattached to the graft using running 4-O prolene.

Thank you!

 

[dimmitta]

Based on the documentation provided, I would suggest coding CPT 33860.

 

[coop22]

The aortic aneurysm codes that I would use for this op-note

33860 & 33870,52,59 (XS)

 

[Babsss]

questions

Could you explain why you used both codes to which part of the surgery. I have a similar case and just don't feel comfortable. If you could look at this for me. I will not bore you with all of the op note.
OP Note:
A median sternotomy was performed, and the left internal mammary artery was taken down. The quality of the left internal mammary artery was good.
I exposed the right subclavian artery for the cannulation. This area had no atherosclerosis. I encircled the right subclavian artery with umbilical tape both proxiamally and distally for the expected cannulation site. I opened the pericardium. The heart was in sinus rhythm, and there was no cardiomegaly.
She had a huge ascending aortic aneyrysm which was 7 cm in diameter. Because the mediastinal incision for about one more inch. I dissected out the innominate vein, a right innominate artery, and the left carotid artery. The innominate artery was encircled both proximally and distally. At this point, I thought this place from the right innominate artery is actually better site for cannulation. After the heparin was given, we sew the 8mm Gore-Tex tube on the right innominate artery and the arterial cannulation was done through this tube. The venous cannulation was achieved by one double-stage venous cannula. I also inserted the left ventricular vent fro the right uipper pulmonary vein and retrograde cardioplegic cannula into the coronary sinus form the right atrium. I separated the ascending aorta from the pulmonary artery as much as I can safely. Then, I encircled the ascending aorta at the very beginning portion of the aortic arch. This was the place for the cross clamp.
The aortic cross clamp was applied and retrograde cardioplegic solution was given. The ascending aorta was opend. I had good blood return from both the right and the left coronary ostium. Aportion of the ascending aorta was excised and I inspected the aortic valve. The aortic value looked somewhat thickened. They were not coapting very well. There was no sign of endocarditis. The sinotubular junction looked normal. Aneurysm starts from after that. I sized the aortic annulus and decided to use size 21 Carpenter-Edwards Magna bovine pericardial valve. This valve was sewn with2-0 ethibond pledgeted stitch at the supraanular fashion. During this valve replacement in progress we were cooling the patient down to 20 degrees. When we completed the aortic valve replacement, the patient had reached the 20 degree mark. Patient was put steep Trendelenburg position. The right innominate artery was snapped between the aortic arch and the cannulation and then we started unilateral antegrade commenced. The aortic cross clamp was removed and I inspected the aortic arch. There was no dissection flap. At this point, my plan was to do hemiarch replacement. The size 30mm graft was sewn at the lesser curvature site of the ascending aorta with 4-0 Prolene running suture. The posterior wall was done in two layers and the anterior was done in one layer. Next, I measured the graft and then I starting doing proximal anastomosis of the graft and ascending aorta. This was done with 4-0 Prolene running suture. The posterior wall was done in two layers and the anterior wall was done in one layer.
The rest is the coronary artery bypass. LIMA to LAD
I coded the 33860, 33405, and 33533. Should I have added the 33870?
Sorry that this was so lengthy.