# ICD 9 Procedure code help needed for lower extremity vascular intervention



## mharrisaapc (Dec 5, 2013)

Hello all...your help is appreciated, this op report is driving me crazy! Need ICD 9 procedure codes for:

PREOPERATIVE DIAGNOSIS:
Limb threatening ischemia, left lower extremity.
POSTOPERATIVE DIAGNOSIS:
Limb threatening ischemic, left lower extremity.
PROCEDURES:
1. Left popliteal and tibial thrombectomy through medial cut down.
2. Iliofemoral thrombectomy x4.
3. Left common femoral endarterectomy through left groin incision.
4. Left profunda femoral endarterectomy.
5. Medial compartment fasciotomy.

INDICATIONS:
The patient is a 48-year-old white female who has undergone a procedure
earlier today for revascularization of the left lower extremity, which
included an attempt at percutaneous thrombectomy of thrombus involving the
popliteal and tibial vessels. Today, she had a TPA infusion in an attempt to
lyse any distal residual thrombi as well as more proximal thrombi in the
iliofemoral system. After approximately a 6 hour infusion, we re-evaluated the
circulation distally and felt that the only chance for limb salvage at this
point would be open thrombectomy and indicated procedures. The procedure risks
and alternatives were discussed with the patient, her father and her
significant other. Among potential complications discussed were bleeding,
hematoma, limb loss, nerve damage. Inquiries about the procedure were invited
and addressed. The patient's father acknowledged that he understood and
consented to operation.

FINDINGS:
The patient's common femoral artery and profunda femoral artery were
completely occluded. Despite the profunda femoral endarterectomy, we were not
able to get satisfactory back bleeding.

We did remove thrombus from the iliofemoral popliteal segment and got
reasonable inflow. We will were also able to extract a few thrombi distally.
At one point, we did have much improved appearance to the foot, however, the
Doppler signal distal to the arteriotomy was gradually lost. We actually performed thrombectomy approximately 4 times. In an attempt to improve inflow
from the iliac artery, we exposed the left common femoral artery at the
inguinal ligament and performed endarterectomy. We were able to get fairly
good inflow from the iliac artery, but once again, we were not able to sustain
pulses distally. It is felt that the outflow for limb salvage is extremely
poor at this point. Unfortunately, there do not appear to be any other viable
options for limb salvage at this point.

PROCEDURE:
With the patient supine under satisfactory general anesthesia, the abdomen and
lower extremities were prepped and draped in a sterile field. The popliteal
artery was exposed through a medial skin incision just distal to the knee. The
artery was exposed for approximately 5 or 6 cm. Vessel loops were used for
control purposes. We made a small vertical arteriotomy after giving IV
heparin. Using 2 and 3 Fogarty a distal tibial thrombectomy was carried out
with result as noted above. We then used 3 and 4 Fogarty to clear thrombus
proximally from the iliofemoral segment. Inflow was felt to be reasonably
good. The arteriotomy was then closed with a bovine patch anastomosed in place
with 6-0 under loop magnification. At this point, we did have a good pulse in
the popliteal artery and a monophasic signal in the posterior tibial with
improvement in the appearance of the foot.

We were about to close when we re-evaluated the foot. The color had
deteriorated and our signal was lost. We then reoccluded the popliteal artery
and an arteriotomy was made transversely proximal to the initial arteriotomy.
We again used 3 and 4 Fogarty to perform thrombectomy proximally as well as
distally. Once again we extracted thrombus. The arteriotomy was again closed
with 6-0 Prolene. Flow was restored, but unfortunately the same sequence of
events occurred with gradual loss of Doppler signal in the popliteal. At this
point, a medial fasciotomy was made. We did use a small counter incision
distally on the medial aspect of the calf to open up the fascial compartments.
I felt that this might be contributing to loss of the pulses. This did not
improve the situation and at this point we elected to expose the common
femoral artery. This was extremely difficult owing to the patient's body
habitus. We were eventually able to expose the common femoral artery down to
the femoral bifurcation. Vesseloops were placed around the profunda femoral. A
vertical arteriotomy was then made in the common femoral and an endarterectomy
was carried out. We also performed another thrombectomy of the external iliac
with a 5 Fogarty. Again we passed the Fogarty down the SFA and popliteal.
There was fairly minimal thrombus obtained. In addition, we performed
endarterectomy of the profunda, but we were not able to obtain any significant
back bleeding from it. We did use tacking stitches on the plaque endpoints.
These were 6-0 Prolene. We were able to pass dilators proximally and distally
through the artery so there was no compromise by the closure procedure. This
was also true of the popliteal artery in which we were able to easily pass a 2 mm dilator proximally and distally. The femoral arteriotomy was then closed
and flow restored. Once again, we appeared to have good flow initially but
this was lost.

We performed an arteriotomy through the popliteal incision one final time. The
artery was occluded and a vertical arteriotomy was made. We did extract a
small amount of thrombus and obtained some inflow. At this point, the
appearance of the foot was quite cyanotic and it was cool to palpation. After
performing the thrombectomy, the arteriotomy was again closed with 6-0
Prolene. Flow was restored. At this point, I felt we had thoroughly exhausted
all reasonable options for limb salvage. Further, I felt that prolonging the
procedure could potentially threaten the patient's life. The wounds were then
made hemostatic. They were thoroughly irrigated out with an antibiotic
solution. We then closed each in layers with 3-0 Vicryl. The skin was
approximated with staples and sterile occlusive dressings were placed.
While the patient was in the operating room, the sheath was removed. Prior to
removing the sheath, we checked an ACT and it was found to be 190 seconds. I
removed the sheath and held pressure manually for 15 minutes. The right groin
was carefully inspected and found to be hemostatic prior to moving the
patient. All sponges and needle counts were reported correct. The patient was
then transferred to ICU.


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## jewlz0879 (Dec 31, 2013)

I would go with 444.22

HTH


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