Please Help! At a total lost on how to code this note.

Pre-op dx: left leg ischemia, cardiogenic shock, ecmo requirement
Post-op dx: left leg ischemia, cardiogenic shock, ecmo requirement

Name of Procedure:
1. Insert of rt femoral ecmo arterial cannual w/8mm Dacron conduit
2. Removeal of left femoral arterial ecmo cannula w/repair of left femoral artery

Indications: 43 year old femal has undergon emergency complicated coronary revasularization w/a left main occlusion, cardiogenic shock, mitral and tricuspid valve repair, was placed on Ecmo w/inability to wean off from the pump, has an open chest, and noted to have a very cold, pale left foot with ECMO cannula in place. She had intra-aortic balloon placed through the right groin and is taken urgently to the OR for explantation of left femoral cannula to be put in a conduit to allow perfusion distally on the right.

Description of Procedure: the patient was taken from the intensive care unit to the OR and transferred gently to the stretcher with all of her various lines. After appropriate pause for patient identification, site, and procedure both groins, lower abdomen, and thighs were prepped and draped in sterile manner with Chloraprep. Vertical incision was made over the sheath from the intra-aortic balloon. This was carried down throught subcutaneous tissue with electrocautery. Tracing this to the inguinal ligament, the entrance site was noted. The patient was heparinized with 5000 units, the artery was occluded distally, the balloon deflated, and the sheath and balloon then removed from the artery clamping proximally. The artery was then opened in a vertical fashion and cleaned of its areolar attachments. An 8 mm x 15 cm Hemashield graft, to be used as conduit, was then swen in an end-to-side fasion to the common femoral arter with a running suture of 5-0 Prolene. Good flow and hemostasis was noted. this conduit was then withdrawn benath the subcutaneous tissue through the skin. A new arterial cannula 20-French was then placed in this, secured numerous positions, allowed to backbleed, and then connected to the ECMO curcuit using tubing clamps for the left femoral cannula. This provided adequate flow, although increased bleeding was noted with pressurized system and return of blood through this very thing-walled artery. There was diffuse bleeding from all needle holes. A vertical incision ws then made in the left groin where there was both an arterial and venous cannula; the arterial being the 20-French sheath, the venous being the 24-French sheath. With sharp disection and use of electrocautery, the arterial sheath was traced down to it's insertion in the common femoral artery just distal to the inguinal ligment. The artery was clamped both distally and then the catheter was withdrawn, the artery clamped proximally. This was a fairly clean transverse insertion, although it took up the entirety of artery. A 4 Fogarty catheter was passed distally, productive of no thrombus in the left femoral artery with good back flow. The artery was hen cleaned of its areolar attachments and arteriotomy closed in transverse fashion with interrupted sutures of 6-0 Prolene. After flushing, clamps, were released. Adequate flow was noted, but again there was diffuse oozing from all needle holes. The correction of the coagulopathy required 200 milligrams of protamine, numerous blood products including red blood cells, fresh frozen plasma, cryo, and platelets to be tabulated at another time. Following successfull hemostasis with numerous patch sutures, products, and clotting aids, the left groin was closed in 2 layers, with running sutures of 3-0 Vicryl, skin closed with running subcuticular stitch of 4-0 Monocryl. Similar closure was used on the right side. The patient was then transferred back to ICU. the left calf was soft with no compartmental hypertension. There was capillary refill in the right toes, but with the ECMO circuit, no Doppler signals were present.

Any help on coding this would be appreciated!
Heidi CPC