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Need vascular note help!

  1. #1
    Default Need vascular note help!
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    I have no idea where to start with this note. Any help would be appreciated.


    PREOPERATIVE DIAGNOSES:
    1. Postphlebitic syndrome of left lower extremity.
    2. Occlusion left external and common iliac vein.

    POSTOPERATIVE DIAGNOSES:
    1. Postphlebitic syndrome of left lower extremity.
    2. Occlusion left external and common iliac vein.

    PROCEDURES PERFORMED:
    1. Left common femoral vein exposure.
    2. Endo venectomy of left femoral vein.
    3. Left to right femoral vein bypass using PTFE graft.
    4. Arteriovenous fistula left superficial femoral artery to femoral femoral vein bypass.

    FINDINGS:
    1. Chronic deep venous thrombosis present in the left common femoral vein that was meticulously removed using tenotomy scissors to perform a complete Endo venectomy of the common femoral vein and distal left external iliac vein.
    2. Good thrill in the right common femoral vein after bypass.


    SPECIMENS REMOVED: The Endo venectomy of the left common femoral vein.

    PROSTHETIC IMPLANTS:
    1. An 8 mm Propaten graft used for the femoral vein to femoral vein bypass.
    2. A 4 mm Bard PTFE to create a left SFA to femoral vein bypass.

    INDICATIONS FOR PROCEDURE: The patient is a 28-year-old female who had previously undergone trauma and subsequent chronic occlusion of her left external and common iliac veins. An endovascular approach to open this had failed. She now presents for a Palma procedure extending a bypass from the left to the right femoral vein as well as an Endo venectomy with removal of any chronic disease from the left common femoral vein and left distal external iliac vein. The patient will also have a fistula created between the left superficial femoral artery and the femoral vein to the femoral vein bypass in order to have increased flows and reduce the risk for thrombosis.

    DESCRIPTION OF PROCEDURE: Using a 10 blade a vertical incision was made in the bilateral groins. The common femoral veins were carefully identified and dissected and all of its branches were preserved including the pudendal veins, the femoral vein, the profunda vein, the saphenous vein, the external iliac vein bilaterally. Once control was obtained a tunnel was created on the suprapubic region and the soft tissue superficial to the fascia to the abdominal wall. This was performed with a large clamp. An umbilical tape was then passed. The patient was then given 100 units per kilogram of heparin. ACT was obtained at three minutes. ACTs were managed to be kept above 250 and the ACT values were obtained every 45 minutes thereafter. At this time, venotomy was then performed in the left common femoral vein, identifying significant synechiae within the common femoral vein itself. Using a pair of tenotomies and _____ the synechiae and chronic thrombus were removed from the left common femoral vein, left femoral vein and left distal external iliac vein. Upon completion of the Endo venectomy, the profunda, femoral and saphenous veins were all opened and ensured good flow. At that time an 8 mm PTFE graft was sewn into position using a 5-0 Prolene suture in running fashion. The graft had been previously tunneled and at this time the right common femoral vein was clamped and opened with an 11 blade followed by extension with the Potts scissors and the graft was sewn into position using a 5-0 Prolene suture in running fashion. Once the left femoral vein to right femoral vein bypass graft was completed, the left superficial femoral artery was controlled and was opened using an 11 blade extended with the Potts scissors and a 4 mm to 7 mm Bard PTFE graft was then sewn with a 4 mm end into the superficial femoral artery. The graft was extended up to the femoral vein to femoral vein bypass and sewn into position using a 5-0 Prolene suture in running fashion. Upon completion, the irrigation was performed in both groins. Hemostasis was assured. The patient had a palpable thrill in the right common femoral vein and right external iliac vein. She did not have a thrill in the profunda or the femoral vein on the right. This indicated good flow towards the central system. At this time, the groins were closed in three layers using 3-0 Vicryl sutures, followed by a 4-0 Vicryl for the skin and Dermabond for the skin. The patient was allowed to awaken from anesthesia found to be in stable condition, and was taken back to the postanesthesia care unit in stable condition.

  2. #2
    Default the codes
    I might be way off but I was thinking 35371, 35351, 35661, 35686.

  3. Default
    Well I have to say I have never seen anything like this. But I have looked at the CPT and there is NO differental that when they say femora-femoral bypass graft they are meaning only arterial. So I would say use 35661 and then use 35686 for the femoral fistula. I hope someone else has some input also, would like to hear what everyone thinks.

  4. Default Palma procedure
    I just got the same scenario... We are scheduling a Palma for tomorrow ...I am not sure if we should use an unlisted or use the 35661... I have always been under the impression these were only arterial???
    Last edited by BERNADETTEMD; 02-02-2015 at 01:09 PM.

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