Ok, this is a co-surgery for the tumor removal. The other surgeon billed 39220. I am trying to bill the vascular part. I was looking at 34502 for the reconstruction of the vena cava. Also 35681 for the saphenous vein removal. Now I am not sure what to use for the grafting of the 3 veins. I know that code 33335 is normally used for cardiac wounds, but I was looking at that. It does not fit exactly, but I just could not find a vein to vein code that fit. Any help would be great!!


PREOPERATIVE DIAGNOSIS (ES): MUCIN-PRODUCING CARCINOMA OF THE ANTERIOR
MEDIASTINUM.

POSTOPERATIVE DIAGNOSIS (ES): MUCIN-PRODUCING CARCINOMA OF THE ANTERIOR
MEDIASTINUM.

PROCEDURE PERFORMED: REOPERATIVE RESECTION OF THE ANTERIOR MEDIASTINAL TUMOR
WITH EN BLOC RESECTION OF THE RIGHT PHRENIC NERVE, SUPERIOR VENA CAVA, PROXIMAL
RIGHT INTERNAL JUGULAR VEIN, AND LEFT INNOMINATE VEIN; RECONSTRUCTION SUPERIOR
VENA CAVA, RIGHT INTERNAL JUGULAR VEIN, AND LEFT INNOMINATE VEIN USING SPIRAL
SAPHENOUS VEIN GRAFT; ENDOSCOPIC RIGHT GREATER SAPHENOUS VEIN HARVEST.


ANESTHESIA: General endotracheal.

DESCRIPTION OF OPERATION: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. Central access
and arterial access was obtained by the Anesthesia Team for intraoperative
monitoring. The patient was subsequently prepped and draped in the usual
sterile fashion from the chin to the toes. The right greater saphenous vein
was then harvested endoscopically in the usual fashion. A midline sternotomy
was made using an oscillating saw for the anterior sternal table and a straight
Mayo scissors for the posterior table. There was tumor involving the posterior
table in one section of the sternum right at the sternomanubrial junction.
This area of posterior table was excised on entry and sent to Pathology.
During initial exploration after sternotomy, Dr. ------ Team entered the
operating suite and carefully evaluated the extent of the tumor. We determined
that there was gross invasion of the right phrenic nerve, the superior vena
cava, the left innominate vein, and the proximal aspect of the right internal
jugular vein. The left phrenic nerve appeared to be free of gross tumor and
the aortic arch itself and great arterial vessels appeared to be free of tumor.
We were able to create a plane between the tumor and the arch safely. After
adequate mobilization and dissection of the great vessels and the tumor itself,
prior to resection, we then fully heparinized the patient and then cannulated
her for cardiopulmonary bypass.

Cannulation was as follows: There was a dual-stage placed in the right atrial
appendage. There were also two additional venous cannulae, one placed in the
right internal jugular vein and one placed in the distal left innominate vein
beyond the area of tumor invasion in order to completely isolate SVC, left
innominate vein, and proximal right IJ, so that these veins could be resected
en bloc with the primary tumor. She was then placed in cardiopulmonary bypass,
and we then placed venous occlusion clamps across the left innominate vein
proximal to the cannulation site, across the right internal jugular vein
proximal to the cannulation site, and across the SVC-RA junction. This
completely isolated the veins other than the azygos vein which drained also
into the tumor mass. After isolating these great veins, we then resected the
tumor en bloc including the right phrenic nerve, the SVC, left innominate vein,
and the proximal aspect of the right internal jugular vein. The tumor was then
passed off and sent to Pathology. We then sent frozen sections of all the
margins beyond where the en bloc resection had been performed to confirm
whether or not there were any additional signs of microscopic disease and in
fact, several of the specimen beyond the margin of resection came back as
questionably positive whereby they saw some mucin, although, they could
identify no tumor cells. We confirmed we could identify no evidence of gross
residual disease.

We then proceeded with venous reconstruction. Again, we had harvested the
right greater saphenous vein and during the time when Dr. ------ team was
evaluating the extent of the tumor burden and dissecting the mediastinal
structures, I created a spiral vein atop a 40-French catheter to establish a
40-French diameter spiral vein. I took a segment of that full length of the
spiral vein to create a second spiral vein and then, I made an oblique venotomy
in the already created 40-French spiral vein in approximately two-thirds down
its length and then, I anastomosed a second shorter segment of the spiral vein
with a length of approximately 6 cm and again a diameter of 40-French. That
was anastomosed to the primary spiral vein using running 6-0 Prolene suture.
The spiral vein itself was created again with running 6-0 Prolene suture. This
created a Y-shaped bifurcated spiral vein all with a caliber of 40-French.
This was then used to reconstruct the left innominate vein, superior vena cava,
and distal right innominate vein, and proximal right internal jugular vein.

We transected the right innominate vein at the right IJ junction and superior
vena cava approximately 1 cm distal to the SVC-RA junction. We then
anastomosed each of the three cut ends of the great veins in an end-to-end
fashion to the Y-shaped spiral vein. Each of these anastomoses was completed
with running 6-0 Prolene suture. We sent the SVC margin to Pathology just
prior to beginning that SVC to spiral vein venous anastomosis and after
completing the venous reconstruction, the frozen section of the SVC margin
returned as potentially positive again adjacent to the adventitial tissues,
although, no distinct carcinomatous cells were identified. Nonetheless, it
raised concern about a positive margin at the SVC and thus, we elected to
resect another centimeter of SVC. In doing so, this left some slight tension
on the SVC reconstruction after completing the anastomosis again and this
created somewhat of a narrowing at the SVC-RA junction anastomosis.

Therefore, I harvested a remote segment of pericardium down near the diaphragm
and created a native pericardial patch shaped in an elliptical shape. I then
made a longitudinal venotomy of the spiral vein cutting onto the lateral wall
of the right atrium in order to enlarge this area of reconstructed SVC. The
elliptical-shaped patch was then sewn to the neo-SVC to enlarge the caliber
near the RA junction. This again was anastomosed using running 6-0 Prolene
suture. We then checked gradient across the venous reconstruction by measuring
the venous pressure in the right internal jugular vein distal to the
reconstruction as well as right atrial pressure and there was a 6 mm gradient
with the right internal jugular pressure of 21 and a RA pressure of 14. This
raised some concern about the potential for a stricture formation of the SVC
even though the caliber was approximately 40 French at this location.

Given the length of time required for the entire resection and reconstruction,
I felt it prudent to terminate the case at this time and await the final
pathologic results. Therefore, the patient was subsequently weaned from
cardiopulmonary bypass. She was subsequently decannulated and the heparin
reversed with IV protamine. Meticulous hemostasis was confirmed. Blake drains
were placed in both pleural spaces and in the mediastinum. The overlying left
pleural tissues were on-laid atop the reconstructed left innominate vein and
SVC to prevent any scarring of the sternum. We then took an oscillating saw
and cut an additional 4 mm of manubrium on each side as well as sternum to
excise any concern of residual tumor in the posterior table of the manubrium.
This still allowed enough residual manubrium to facilitate closure and the
manubrium and the sternum were then reapproximated with interrupted heavy gauge
wire.

The pectoralis fascia, subcutaneous tissues, and skin were all approximated
with running absorbable sutures. Similarly, the right lower extremity incision
was closed in layers with running absorbable sutures. The patient tolerated
the procedure well and was sent to the CT-ICU in stable condition.