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Thread: Need some help coding bypass

  1. #1
    Join Date
    Apr 2007

    Default Need some help coding bypass

    AAPC: Back to School
    Was hoping I could get some help coding this procedure, please.

    PROCEDURE PERFORMED: Right proximal brachial artery to the distal brachial artery orthograde saphenous vein bypass.

    PROCEDURE AND FINDINGS: I was consulted to assess this patient who had sustained the day prior to surgery an injury to the brachial artery, which evolved into the patient having a threatened hand. A preoperative arteriogram had been performed. The patient was taken to the operating room to repair or address an area of brachial artery occlusion that had apparently resulted from a trauma the day prior doing an orthopedic procedure. An attempt had been made to repair the injured artery with a saphenous vein interposition graft. The attempts at this interposition graft were ultimately reported to me as being unsuccessful and I was asked to consult on this patient. At the time of my consultation the patient had had, in the mid upper right arm, exposure of the area of injured artery and one could observe the interposition graft in place. It was reported not to be functioning and intraoperative angiograms had been performed. I reviewed the angiograms and also reviewed the formal angiogram that had been performed earlier in the day. With this background, then I attempted to revascularize the right upper extremity. The incision that had been placed was increased proximally up towards the axilla and distally down towards the antecubital fossa where the incision was taken transversely across the elbow crease and then slightly down the right lateral forearm. The brachial artery was ultimately dissected free and exposed throughout the length of the overlying skin incision. The area of injury and interposition graft was noted. More proximally it appeared there was an area that potentially could have some chronic atherosclerotic disease. Ultimately, in the proximal arm near the junction of the axillary artery into the brachial artery, an area of artery was dissected free and prepared to be the inflow source for a bypass. There was a palpable pulse in this position. Similarly, the artery was examined operatively down towards the elbow and, once again, an area of artery was chosen to be the recipient site for proposed bypass around the area of injury. These 2 areas dissected free, isolated and felt to be adequate as inflow and outflow vessels. Attention was then directed to preparing the conduit. The patient had already had a small area of saphenous vein from the right leg procured and this was done up at the area of the saphenofemoral junction. This incision was increased and the saphenous vein that had not been "harvested" was examined with dissection taken down the medial right thigh. As the vein was followed distally it quickly bifurcated into 2 small vessels that were felt to have dimensions not be adequate for a bypass. This operative site was ultimately closed with 3-0 Vicryl suture and a skin staple. Attention was then directed to the right lower extremity down at the ankle. The area of the natural dissection to expose the saphenous vein at the medial malleolus. This was performed, the skin was incised, subcutaneous space entered. Saphenous vein visualized and followed proximally for a short distance but, once again, this vessel had dimensions that were felt to be too small to function as a conduit. There was a prominent vein in the middle anterior aspect at the ankle and this vein was followed for a certain length but, once again, this vein also did not have adequate length of adequate dimensions felt to be useful for a conduit. Both these sites ultimately had the skin stapled. The right leg was then prepped and draped, and attention was directed to the left femoral area. Skin incision was made, dissection taken down medially overlying what would be the presumed location of the saphenous vein. The saphenous vein was visualized and then it was exposed up to the saphenofemoral junction and it was exposed distally following it down along the thigh medially. When an adequate length was dissected free and felt to be adequate to be used as a conduit for the right upper extremity bypass, the vein distally was controlled with silk ties. On 1 side branch venotomy was made and a dextran/papaverine/heparin solution was infused under pressure to dilate the vein up and better clarify the dimensions of the vein. When this was accomplished, it was felt the vein was adequate to function as the conduit. The vein was then prepared in the usual fashion, side branches being controlled with silk ties and doubly hemoclipped. At the saphenofemoral junction the vein was clamped, the vein incised, and at this point removed and placed in saline solution. A 2-0 silk tie was used to control the stump of the saphenous vein at the saphenofemoral junction. This wound was closed with sequential layers of Vicryl and skin staples. The saphenous vein was then 1 more time dilated with the dextran/papaverine/heparin solution. It was chosen to be used in orthograde fashion. The proximal portion had its ends spatulated. The patient was then given systemic heparin, and the brachial/axillary artery was controlled with vascular clamps and an arteriotomy made. Vascular anastomosis was constructed of the saphenous vein out to its arteriotomy with a running 7-0 Prolene suture. When the vein was "placed on-line" the anastomosis was hemostatically adequate. The vein was then one more time infused with the heparin/papaverine/dextran solution and using inflow pressure a valvulotome was passed from below to incise the valves. Valve incision was accomplished without complication, delivering pulsatile flow into the distal conduit. Distally in a similar fashion, the recipient artery was controlled with vascular clamps, arteriotomy made and the vein distally fashioned to appropriate dimensions and the distal anastomosis accomplished with running 7-0 Prolene suture. Prior to completing the anastomosis, the inflow and outflow vessels were back bled in the anastomotic area and then the anastomosis was completed. Several minor areas of leak from the anastomosis were controlled with simple interrupted sutures. At this point, this restored an actual palpable pulse at the patient's radial artery at the wrist. Hemostasis had been maintained essentially throughout the procedure. The vascular construction status was then examined 1 more time for hemostasis and the wound closed in sequential layers of Vicryl suture and the skin edges coapted. Dry sterile dressings were placed on all the operative sites and the patient delivered to the Intensive Care Unit in a continuing critical condition.

  2. #2
    Join Date
    Apr 2007
    Richardson, TX


    What about 35525? Can't bill harvest of saphenous harvest since it is included.
    Julie Graham, BA, CPC, CCC

  3. #3
    Join Date
    Apr 2007

    Default Thank you

    Thank you jewlz0879 for the help!!

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