# Femoral to posterior tibial bypass w/ vein valvulotomy



## com107 (Apr 30, 2013)

One of my Vascular Dr's did this procedure and I really need some help deciding how to code!

1. A right (superficial femoral artery) to posterior tibial bypass with in situ grater saphenous vein after Valvulotomy.

2. Right superficial femoral endarte
rectomy and right common and deep femoral endarterectomies with bovine patch angioplasties.

3. Angiogram with ligation of arteriovenous fistulae

A longitudinal incision was made in the right groin in between the common femoral artery and the previously identified greater saphenous vein.  Bovie electrocautery was used for hemostasis as well as to dissect down through the subcutaneous tissues to the level of the femoral sheath.  The sheath was incised longitudinally. The greater saphenous vein was then identified and cleared circumferentially for several centimeters both proximally and distally.  Small branches were controlled with silk ties.

Next the femoral arteries were exposed.  Dissection proceeded proximal to the inguinal ligament to identify a soft portion of the artery that could be clamped.  After exposing the common, deep and superficial femoral arteries vessel loops were placed both proximal and distally.  The patient was on a heparin drip preoperatively. A clamp was placed proximally.  The distal arteries were controlled with vessel loops.  A longitudinal arteriotomy was made in the common femoral artery and extended distally into the deep femoral artery to the level of it second branch.  Exophytic calcified plaque was removed after entering into an endarterectomy plane.  This plaque was submitted as a specimen.  The arteries were then flushed vigorously.  A tailored swatch of bovine pericardium was used to repair the anteriotomies using a 5-0 Prolene suture using a two point technique.  Before the final sutures were placed the arteries were backbled and flushed in the usual fashion.  The patch was completed.  Small bleeding points along the patch were controlled with 6-0 Prolene sutures.  Flow was reestablished through the common and deep femoral arteries.  Doppler confirmed adequate signals.

The greater saphenous vein was divided at its junction with the common femoral vein.  The common femoral vein was repaired using a running 5-0 Prolene suture.  The greater saphenous vein was mobilized by dividing several of it branches.  The end of the vein was speculated and the proximal valves excised sharply.  With mobilization the vein could not reach the area of the common femoral artery.  To create a tension free anastomosis the superficial artery was opened longitudinally after controlling the common and deep femoral arteries.  An endarterectomy was preformed.  An end to side anastomosis was created between the greater saphenous vein and the superficial femoral artery using a running 5-0 Prolene suture.  Before the final sutures were placed the artery and graft were backbled and flushed in the usual fashion.  With completion of the proximal anastomosis the vein then distended to the area of the next valve. 

The greater saphenous vein and the posterior tibial artery at the level of the ankle were then exposed through a longitudinal incision.  The greater saphenous vein was divided and the distal end was ligated using silk suture.  The LeMaitre valvulotomy was then advanced through the open distal portion of the greater saphenous vein. It was delivered proximally to just below the anastomosis.  It was passed without difficulty.   The valvulotomy was then used to cut the valve.  This was done several times until pulsatile bleeding was noted from the distal end of the greater saphenous vein.  A longitudinal arteriotomy was then made in the posterior tibial artery. Backbleeding was noted.  An end to side anastomosis was created between the vein and the posterior tibial artery using a 6-0 Prolene suture.  Prior completion of the anastomosis the artery and graft were backbled and flushing in the usual fashion.

A 5-french sheath was then introduced through the common femoral artery patch and an arteriogram was performed.  The location of the arteriovenous fistula were marked on the leg with the aid of a Glow 'N Tell tape. Several of the fistulae communicated with the deep system.  The distal anastomosis was proceeded to identify the saphenous vein graft as well as the fistulae.  The fistula were clipped.  It was during the exposure of one of the fistulae that there was noted to be an area of injury to the wall of the vein likely from the valvulotome.  While the wall was intact it was weakened.  This was repaired using a 5-0 Prolene suture with care not to narrow the graft.

A repeat venogram showed further AV fistulae that were ligated in a similar fashion.  The fistulogram also showed a lack of flow distally in the vein.  The graft now had an obstructive signal on Doppler.  It did have a pulse but there was a concern that is may be transmitted pulse from more proximally.  There was a concern for a thrombus and therefore a #3 Fogarty catheter was introduced via a venotomy in the proximal greater saphenous vein.  The Thrombectomy catheter was advanced and withdrawn several times.  No thrombus was identified.

Decision was made to evaluate the distal anastomosis.  A venotomy was made on the hood of the graft.  There was no backbleeding from the posterior tibial artery.  Decision was made to take down the distal anastomosis and resew it.  The arteriotomy was extended through calcified plaque.  Now backbleeding was noted from the posterior tibial artery. At this point the posterior tibial artery would admit 2 mm dilator.  The distal anastomosis was re-done with the aid of a bovine pericardial patch and a 6-0 Prolene suture.  The graft and the posterior tibial artery now had a triphasic signal.  An angiogram was repeated from the groin.  Contract would only make it to the level of the knee.  There was evidence of reflux of the contrast more proximally.  There was a concern that this was in an area of an uncut valve.  A skin incision was made in this area and the vein explored.  An AV fistula was identified and this was ligated with a clip.  A transverse incision was made in the vein in the area of the valve and the valve excised.  The vein was repaired using 5-0 Prolene suture.  Doppler in this area now confirmed adequate signals where as prior to this there was more of an obstructive signal.  Repeat angiogram was unchanged in the fact that no distal flow could be identified.

Decision was made to reevaluate the distal anastomosis.  A transverse venotomy was made in the distal greater saphenous vein.  No backbleeding was noted from the posterior tibial artery.  The posterior tibial artery would admit a 2 mm dilator.  After passing the dilator there was now backbleeding from the posterior tibial artery.  Completion venogram was performed from the distal greater saphenous vein.  This revealed that there was no direct flow from the graft into the posterior tibial artery.  The posterior tibial artery did reconstitute via collaterals.

At this point decision was made to terminate the procedure.  The groin was closed in multiple layers with Vicryl suture and the skin reapproximated using staples.  Sterile dressings were placed.  Needle, sponge and instrument counts were correct at the end of the case per the nursing staff.


Thank you in advance for you help

Sandy


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