# Please help with bypass graft coding



## lovetocode (Dec 12, 2011)

Hey, thanks in advance for all the help and advice.  I am looking at CPT codes 35585, 35566, or 35666.  Any clues/tips to help distinguish between in-situ vein, vein, or other than vein will also be appreciated.  I know the op report is long, but thank you for your time and advice.

PREOPERATIVE DIAGNOSIS:
1. Atherosclerotic occlusive disease, rest pain, right lower extremity.
2. Thrombosis embolism, right lower extremity.
3. External iliac artery stenosis.

POSTOPERATIVE DIAGNOSIS:
1. Atherosclerotic occlusive disease, rest pain, right lower extremity.
2. Thrombosis embolism, right lower extremity.
3. External iliac artery stenosis.

OPERATION PERFORMED:
1. Right femoral to anterior tibial artery bypass using a Miller vein cuff.
2. Unilateral extremity venogram.
3. External iliac artery stenting 7 x 59 I cast and also a 7 x 50 Viabahn.
4. Thromboembolectomy of the tibial level.
5. Thromboembolectomy of the iliofemoral level.
6. Right two-compartment fasciotomy.

ASSISTANT:
Liam Smith.

ANESTHESIA:
General.

ESTIMATED BLOOD LOSS:
About 200.

TRANSFUSION:
3 units of blood.

URINE OUTPUT:
200.

DRAINS:
None.

CONDITION:
Critical to the ICU.

COMPLICATIONS:
None.

SPECIMENS:
Clot was discarded.  It was an acute clot and that is an abnormal.

FINDINGS:
She has a palpable pulse at completion after thrombectomy and bypass.  Her
anterior compartment muscle is marginal and she will need to have this watched
very closely over the next couple of days to see if it is viable.  It did not
twitch very well and __________  at all with the Bovie cautery.

ANGIOGRAPHIC FINDINGS:
Common iliac artery is widely patent.  Profunda femoral artery is stenotic but
patent.  External iliac artery is heavily diseased and stenotic.
Postprocedure, it was widely patent.  The common femoral and profunda femoral
artery are widely patent without stenosis or thrombosis.  The proximal bypass
done yesterday is patent proximally post thromboembolectomy.

Completion angio not done because the pulse was palpable.

INDICATIONS FOR PROCEDURE:
A 68-year-old white female who over the last year has had multiple operations
on the right lower extremity including a fem-pop lysis, an angio and most
recently in the last couple of days presented with acute rest pain again and a
thrombosed fem to below knee pop bypass graft, failed lysis yielded a redo fem-
pop bypass yesterday which thrombosed last night.  Her motor and sensation in
her foot gradually worsened and worsened and she was brought to the OR this
morning first thing emergently in order to restore flow to her foot.  She is
here with a foot that she cannot move very well.  She can just wiggle it and
her sensation is not intact.  She has venous signals but no arterial signals.
The foot is beginning to be more and more mottled. It is not purple and
complete mottled yet.

It was discussed with her that the risk of amputation is very high at this
point.  She wished to proceed with an operation.  We did discuss it with her
daughter via telephone since the patient was slightly confused this morning.

PROCEDURE:
Patient was brought to the OR and placed supine.  Anesthesia acquired,
monitoring lines placed, prepped and draped in standard surgical fashion,
antibiotics infused.  I decided to stay out of the groin or risk infection of
this groin, so I made an incision about 6 inches below the groin.  We dissected
out the bypass that was placed yesterday.  It is an 8 mm PTFE Propatent.  Once
this was done, we encircled it with vessel loops.  I then dissected out the
anterior tibial artery on the right lateral leg and at this time noticed the
muscle to be bulging so I did perform full fasciotomies of the right anterior
and lateral compartment.

My thinking of the posterior superficial compartments is that they had already
been opened up by Dr. Gill the prior day on the fem-pop bypass, so I did not go
back into this incision.

At this time I dissected out the anterior tibial artery.  It was found to be
thrombosed.  I gave the patient heparin and kept her heparinized with an ACT
greater than 250 throughout the remainder of the case.  At this time I opened
up the anterior tibial artery and thrombectomized it proximally and distally
pulling out acute clot.  I was able to get latex-free Fogarty down to the pedal
arch and once this was done and no more passes brought acute clot I injected 4
mg of t-PA down the anterior tibial artery to the foot and flushed it with
heparinized saline.  I then put a bulldog clamp on the anterior tibial artery
proximally and distally to where I had opened it up longitudinally.

At this time I then took the graft.  I transected it with care not to lose it,
tied it off distally with two 2-0 silk sutures and proximally removed the
rings, put a hemostat on it and then thrombectomized it.  I was able to
thrombectomize all the way up into the aorta but the inflow was very poor, just
kind of a dribble.  At this time I clamped it, put an 8-French sheath in.  I
actually put a 6 and then an 8-French sheath in and used a bare and a glide to
put a catheter in the distal aorta and performed a right lower extremity runoff
showing the external iliac artery stenosis.  I did not see any acute thrombus.

I then did a retrograde arteriogram showing a common femoral, profunda femoral
and the proximal graft to be widely patent without evidence of thrombus or
stenosis, so at this time I made a decision to stent this external iliac artery
just distal to the internal iliac artery.  I did this with a 759 I case and a 7
x 50 Viabahn stent __________  with a 6 balloon.  We had excellent result with
great pulsatile inflow at this time.

With this, I was very happy with the result, so instead of filling a graft to a
graft in this region I took the Gore hybrid graft which has a Viabahn on one
side and a PTFE on the other side and I deployed the Viabahn as a 9 inside the
8 mm ringed PTFE graft.  I then placed 4 stay sutures, so it  would not be
pulled out.  Hemostasis was achieved.  I then took the Gore tunneler and
tunneled it superficially in the subcu just above the knee going to the middle
of the joint laterally down to the anterior shin.

Once this was done I pulled the graft through there.  We inspected the
anastomosis up top.  It looked very good, made sure nothing was kinked,
pulsatile inflow down below the knee at this point was noted.  At this time I
harvested vein from the left groin and I then took the vein.  I cut it
longitudinally, fashioned it and then sewed it onto the anterior tibial artery
for an area of 1.5 cm in the fashion of a typical Miller vein cuff.

Once this was done I was very happy with this so I then sewed the 6 mm
Propatent hybrid end onto the Miller vein cuff using PTFE suture.  Once this
was done I de-aired the graft and then let it go retrograde up the anterior
tibial artery, then prograde.  At this time the patient had a palpable dorsalis
pedis pulse and she oozed quite a bit.  I did reverse it with 10 mg of
protamine and up top there was a little bit of oozing so we used Gelfoam,
thrombin, FloSeal and placed some extra stitches.  Down below the cuff repair
stitches were used to obtain hemostasis.

At this time she was very oozy.  We applied FloSeal and thrombin.  I did take
the graft and I tucked it in between the bellies of the flexor hallucis longus
and flexor digitorum longus and closed the muscle loosely with a Vicryl over
the top of the graft.  More proximally, I could not cover it with a muscle
because the fascial layers were turning in the tendon, so I closed the skin for
a distance of about 2 inches.  With this, I had complete graft coverage.  I was
very happy with the results, so we closed the right thigh wound in addition to
the left groin wound in layers with Vicryl and Monocryl, and Dermabond placed
on the left thigh in the right groin.  Wet-to-dry was placed over the muscle
tissue on the fasciotomy site.

She did not drop her pressure once we released the ischemic leg.  She was
stable throughout and she tolerated the procedure relatively well.  She will be
going to the ICU in stable condition.  She had a large loss of limb due to
muscle viability which we will follow over the next couple of days


----------



## TonyaMichelle (Dec 12, 2011)

This is what I came up with:


*so at this time I made a decision to stent this external iliac artery
just distal to the internal iliac artery.*
37221 (Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement, includes angioplasty within same vessel, if performed)

*At this time I dissected out the anterior tibial artery. It was found to be
thrombosed. I gave the patient heparin and kept her heparinized with an ACT
greater than 250 throughout the remainder of the case. At this time I opened
up the anterior tibial artery and thrombectomized it proximally and distally*34203 (Embolectomy or thrombectomy, with or without catheter; popliteal-tibio-peroneal artery, by leg incision)

*I then dissected out the
anterior tibial artery on the right lateral leg and at this time noticed the
muscle to be bulging so I did perform full fasciotomies of the right anterior
and lateral compartment.*
27600 (Decompression fasciotomy, leg; anterior and/or lateral compartments only)

36200-59 (Introduction of catheter, aorta)*This code is used in addition to the venogram.*

*I
actually put a 6 and then an 8-French sheath in and used a bare and a glide to
put a catheter in the distal aorta and performed a right lower extremity runoff
showing the external iliac artery stenosis. I did not see any acute thrombus.*
75820 (Venography, extremity, unilateral, radiological supervision and interpretation)

*At this time I
harvested vein from the left groin and I then took the vein.* 
+35572 (Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure)

*so instead of filling a graft to a
graft in this region I took the Gore hybrid graft which has a Viabahn on one
side and a PTFE on the other side and I deployed the Viabahn as a 9 inside the
8 mm ringed PTFE graft.*35883 (Revision, femoral anastomisis of sythetic arterial bypass graft in groin, open; with nonautogenous patch graft{eg, ePTFE})


----------

