# vascular sx/endarterectomy w/ligation of carotid



## tlewis8642@sbcglobal.net (Jul 19, 2013)

Any thoughts on the CPT codes on this??
I am considering billing the 35301 - endarerectomy, 37605-Ligation, and the attempted bypass graft - 35601-53 

PROCEDURE DESCRIPTION:  The patient was taken to the operating room, placed
in supine position on the operating table.  After adequate IV sedation,
general endotracheal intubation the right neck and chest were prepped and
draped in the usual sterile manner.  Once draping was completed, a 10 blade
was used to make an incision anterior to sternocleidomastoid.  This was
extended down to deep subcutaneous tissues and platysmal layer.  The common
facial vein was isolated, doubly clipped and ligated.  With blunt and sharp
dissection the common carotid, external carotid, distal internal carotid
vessels were freed and loops placed around them.  A total of 4,000 units of
heparin was administered during the procedure.  Clamps were sequentially
placed on the vessels.  An 11 blade was used to make an arteriotomy
extended with the Potts scissors.  Ulcerative plaque was present at the
carotid bifurcation extending into the internal carotid artery.  The
internal carotid artery had a very small lumen with large amount of plaque
intimal changes.  An 8 mm straight shunt was placed within the internal
carotid vessel as well as the common carotid vessel.  Poor back bleeding
was noted to be present.  Using Penfield dissector, endarterectomy of the
common carotid, external carotid, distal internal carotid vessel was
performed.  Smooth tapered distal plaque was present.  A bovine patch was
cut to the appropriate size using 6-0 Prolene suture.  The patch was used
to close the arterial defect.  Prior to complete closure the shunt was
removed.  The vessel was flushed with heparinized saline and patch closure
completed.  Post patch closure intraoperative Doppler revealed adequate
signals to be present in common carotid and external carotid artery.  Very
poor signal was noted to be present in the internal carotid artery.  It
appeared that there was no high diastolic flow present.  For this reason,
clamps were sequentially placed back within the vessels.  The patch was
opened and it was noted that the vessel itself was quite small in caliber
and fragile.  A 2 forward catheter was passed through the distal wound and
no thrombus in distal lumen, approximately 1 cm, no thrombus present.  Once
again, very poor back bleeding was noted.  The midportion of the internal
carotid artery at the endarterectomy site was then excised.  Attempts to
bypass with additional 6 mm bovine from the bifurcation up into the distal
internal carotid artery in a beveled fashion was completed.  The bovine 6
mm graft was flushed, oriented and marked on its superior aspect.  In the
process of making the anastomosis in the distal artery, it once again tore.
It was quite fragile in nature and had a very small lumen.  Further
attempts to do the bypass were aborted as were the internal carotid artery
was retracting quite cephalad. Ligation of the carotid artery was then
completed with a running 6-0 Prolene suture as well as a 3-0 stick tie.
The stump at the bifurcation was then primarily closed with additional
running 5-0 Prolene suture.  Surgicel Fibrillar was placed around the


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