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Thread: Total aortic arch replacement

  1. #1

    Question Total aortic arch replacement

    AAPC: Back to School
    I have the hardest time coding these. Could someone please take a look at this and see how they would code it. Thanks!!


    PREOPERATIVE DIAGNOSES: Acute type A aortic dissection, mild-to-moderate
    aortic insufficiency.

    POSTOPERATIVE DIAGNOSES: Acute type A aortic dissection, mild-to-moderate
    aortic insufficiency.

    PROCEDURES PERFORMED: Repair of type A aortic dissection, aortic valve
    resuspension and aortic root repair, ascending aortic replacement (28 mm
    Vascutek graft), total aortic arch replacement (26 mm Vascutek graft, 14 mm
    graft for a bovine trunk replacement).

    ANESTHESIA: General endotracheal.

    DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
    placed supine, induced with general endotracheal anesthesia. A Swan-Ganz
    catheter and radial arterial line were placed by the anesthesia team for
    intraoperative monitoring. A transesophageal echocardiogram was performed,
    and this demonstrated an acute type A aortic dissection. There was mild to
    moderate aortic insufficiency, and right and left ventricular function was

    The patient was prepped and draped in the usual sterile fashion from chin to
    toes. A midline sternotomy was made, and then a pericardial cradle created
    to expose the heart and great vessels. The patient was heparinized and then
    cannulated for cardiopulmonary bypass essentially using a Seldinger
    technique. A needle was introduced into the true lumen and a guidewire
    advanced under TEE guidance in the true lumen. The guidewire was then
    serially dilated up, and a 20-French femoral type Edwards catheter was placed
    in the true lumen of the aortic arch to serve as primary inflow. The right
    atrial appendage was cannulated with a dual stage and the superior vena cava
    cannulated with a 26-French soft angled cannula to facilitate retrograde
    cerebral perfusion. A coronary sinus catheter was placed for retrograde
    cardioplegia, and then, the patient placed on cardiopulmonary bypass and was
    systemically cooled to deep hypothermia. We were monitoring the patient with
    continuous EEG and SSEPs throughout the procedure to help direct a safe
    period of deep hypothermic circulatory arrest. During systemic cooling, an
    aortic crossclamp was applied, and initial induction cold blood high
    potassium cardioplegia was delivered retrograde while the ascending aorta was
    transected. We identified the primary tear site in the proximal ascending
    aorta at the sinotubular junction. Upon transecting the aorta, we then
    delivered direct ostial antegrade cold blood high potassium cardioplegia to
    the left and right coronary arteries to complete myocardial protection. From
    that point forward, we maintained myocardial protection using a combination
    of intermittent retrograde and intermittent antegrade cardioplegia. Next we
    carefully inspected the aortic valve. The cusps themselves were of normal
    quality and were deemed acceptable for preservation. Dissection itself
    extended into the noncoronary sinus and portions of the right coronary sinus
    but only halfway down the sinus segment. Consequently, we resuspended the
    aortic valve and repaired the sinus segments using a neo medial
    reconstruction technique with tailored pieces of Teflon felt placed within
    the dissected plane. We then sandwiched the native intima adventitia in neo
    planes around the Teflon felt for a neo medial reconstruction. There was no
    felt internally or externally, only within the aortic wall. It was tacked
    into place using 4-0 Prolene sutures as well as a few pledgeted 4-0 Prolene
    sutures for additional support. This resuspended the valve well. We then
    took a 28 mm Vascutek graft and anastomosed it end-to-end to the aortic root
    for creation of a neo-sinotubular junction. This anastomosis was completed
    with running 4-0 Prolene suture taking care to intussuscept graft into the
    native root for hemostatic suture line. We then connected that graft to the
    cardioplegia circuit and confirmed competency of the valve and gave
    additional antegrade cardioplegia. All the while we were systemically
    rewarming. Upon achieving electrocerebral silence for greater than 4
    minutes, we brief period of deep hypothermic circulatory arrest was
    initiated. The aortic arch was transected obliquely from the takeoff of the
    innominate artery to the distal lesser curve and then we inspected the
    dissected aorta. We then identified a very large distal re-entry tear in the
    distal arch just opposite the level of left subclavian arterial takeoff and
    extending into the descending thoracic aorta. This was quite concerning as
    there was a large secondary tear and in order to exclude it, this mandated a
    total arch replacement. Of note, the patient had a bovine arch anatomy and
    the bovine trunk itself was dissected homing in its very proximal most
    aspect. We replaced the bovine trunk with a 14 mm Vascutek graft. This was
    done first. 14 mm graft was then trimmed to an appropriate length and then
    anastomosed end-to-end to the bovine trunk using running 4-0 Prolene suture
    taking care to intussuscept graft into the bovine trunk. We then connected
    that 14 mm graft to the cardiopulmonary bypass circuit via separate side arm
    and then began antegrade cerebral perfusion to both carotids via this bovine
    trunk, and we completed the rest of the arch reconstruction with continuous
    antegrade cerebral perfusion through this graft. Next we cut the distal arch
    in somewhat of a beveled fashion maintaining inclusion of the left subclavian
    ostium but completely resecting the secondary tear site. Dissection extended
    down the entire descending thoracic aorta beyond the tear site, and just
    beyond the tear site, we tacked the walls with a neo medial piece of Teflon
    felt similar to the root reconstruction placed in dissected plane. Layers
    were once again tacked to one another with pledgeted 4-0 Prolene sutures. We
    then took a 26 mm Vascutek graft and anastomosed it end-to-end to the distal
    arch/descending thoracic aorta using running 4-0 Prolene suture taking care
    to intussuscept graft into the native true lumen for hemostatic suture line
    and to facilitate exclusion of the false lumen. Following completion of this
    distal anastomosis, we then cannulated the graft distally and began
    reperfusing the lower body and once again after appropriately de-airing the
    descending aorta and graft in a retrograde fashion. Once we reconstituted
    the total cardiopulmonary bypass flow, the patient was systemically rewarmed.
    During rewarming, we then made an elliptical graftotomy on the arch graft on
    its proximal greater curve. Then we cut the 14 mm graft in a beveled fashion
    and anastomosed it end-to-side to the arch graft using running 2-0 Prolene
    suture. We maintained antegrade cerebral perfusion during this anastomosis
    and removed the catheter from that graft upon completion of the anastomosis,
    taking great care to ensure de-airing of the entire circuit prior to
    reconstituting antegrade flow through the arch cannulation site. Next the
    proximal aspect of the arch graft and the distal aspect of the root graft
    were each trimmed to an appropriate length and cut in a beveled fashion and
    then the two anastomosed to one another using running 2-0 Prolene suture
    completing the ascending aortic reconstruction. This again was completed
    using running 2-0 Prolene suture. All the while we were systemically
    rewarming and upon achieving normothermia, the patient was subsequently
    weaned from cardiopulmonary bypass with preserved right and left ventricular
    function. The aortic valve was well seated, and there was trace to mild
    aortic insufficiency. The patient was subsequently decannulated. The
    heparin reversed with IV protamine. Meticulous hemostasis was confirmed.
    Temporary atrial and ventricular pacing leads were placed, although the
    patient was in normal sinus rhythm and required no pacing.

    Blake drains were placed in the mediastinum. The overlying thymic fat and
    pericardium were reapproximated from the level of innominate vein to the base
    of the heart protecting all graft material from scarring to the sternum. The
    sternum was reapproximated with interrupted heavy gauge wire. The pectoralis
    fascia, subcutaneous tissues, and skin were all approximated with running
    absorbable sutures. The patient tolerated procedure well and was sent to

  2. #2



    I came up with the following CPT codes:


    dx: 441.01, 424.1

    Let me know if you have any questions.

    Lisi, CPC

  3. #3


    My doctors usually dictate "valve-sparing aortic root remodeling". I was also looking for the coronary artery/vascular graft. Does this make sense to you?

  4. #4


    Your question doesn't make sense to me. LOL. I'm pretty sure this was a valve-sparing aortic root remodeling procedure because they placed a graft in the aortic root and then resuspended the native aortic valve in it.

    I don't understand what you mean by "coronary artery/vascular graft."


  5. #5


    I'm sorry. The question for the vascular part was for the 33870. I was not sure where the head vessels were involved. Then after reviewing the notes further I did find that this was done. Thank you so so much. I have had so many aneuryms to code this week. I am probably trying to depict them too much.

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