# Endarterectomy with patch angioplasty, selective cath, stent placement -- pls review



## dkhclement (May 1, 2018)

Hello - We would love someone to review our codes and provide feedback.  Also, specifically, it's our understanding that we code for both access sites, hence the use of 36140-XS-RT.  Yes/No - Circumstantial?  We are specifically being asked why we want to use this code.

These are the codes we want to use for this inpatient Medicare pt.
35371-RT
37221-RT
36140-XS-RT
75625

Many thanks.  Kristi


Pre-op Diagnosis:
1. Atherosclerotic PVD with intermittent claudication RLE [I70.219]
2. CKD
3. HTN

Post-op Diagnosis: same

Procedure(s):
1. Right common femoral endarterectomy with bovine pericardial patch 
angioplasty
2. Aortogram via L CFA approach
3. Selective catheterization of R EIA 
4. R EIA PTA, stent placement, 8 x 60mm 

Anesthesia: General

Estimated Blood Loss: 200 mL 

CONTRAST: 50 cc

Drain: none 

Total IV Fluids: see anesthesia log

Specimens: 
ID Type Source Tests Collected by Time Destination 
A : RIGHT FEMORAL PLAQUE Tissue Plaque SURGICAL PATHOLOGY 


Implants: 
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No. 
Used 
PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X W.8 CM PERIPHERAL 
STERILE - SN/A Patch PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X 
W.8 CM PERIPHERAL STERILE N/A SYNOVIS MICRO COMPANIES ALLIANCE INC - A 
BAXTER HEALTHCARE CORP CO SP18B02-1270178 Right 1 
mynx       N/A CARDINAL HEALTH INC F1805704 Left 1 


Complications: none

Findings: R EIA occlusion with bulky calcified plaque extending into R 
CFA. S/p endarterectomy. Unable to cross EIA lesion from retrograde 
approach therefore L CFA access was obtained and lesion was crossed from 
an antegrade approach. Self-expanding 8 x 60mm stent was placed was good 
result. Palpable pedal pulses upon completion. 

Disposition: awakened from anesthesia, extubated and taken to the recovery 
room in a stable condition, having suffered no apparent untoward event.

Condition: doing well without problems

Technique: 
After informed consent was obtained the patient was taken to the operating 
room.  Placed in the supine position.  General endotracheal anesthesia was 
administered.  The abdomen and bilateral groins were prepped and draped 
usual sterile fashion. 

We began by making an incision in the inguinal 
right area right groin midline between a cyst in the pubic tubercle in 
vertical fashion. We dissected through the skin subcutaneous tissue 
Scarpa's fascia until we encountered the femoral sheath.  Any veins that 
were seen were tied off and suture ligated.  Then got into the femoral 
sheath identified our inguinal ligament and then our right common femoral 
artery.  It was noted to be calcified with some posterior plaque and some 
inflammation noted. We dissected systemic fashion inferiorly identifying a 
few branches and putting small Vesseloops around.  We then identified the 
SFA and profunda.  Placed vessel loops around them.  We then continued our 
dissection more proximally we had to divide part of the inguinal ligament 
to get more proximal control. 

At this point, we began our endarterectomy 
we heparinized the patient and obtained ACTs every 30 min to remain 
therapeutic.  Once the patient was therapeutic we got control with vessel 
loops and then performed an arteriotomy with an 11 blade and extended it 
with Potts scissors. The common femoral artery had noted hemorrhagic 
calcified plaque.  We then perform an endarterectomy between the median 
intima with a Freer elevator and piecemeal off the plaque in the common 
femoral artery.  We then made our endpoint at the distal common femoral 
artery.  There was noted to be calcified posterior plaque on the proximal 
aspect of our endarterectomy site with a chronic occlusion.  

We attempted 
to access through the open endarterectomy vessel the right external iliac 
artery with a Glidewire 035 as well as a 5 French sheath.  When we 
advanced the wire and there was mild resistance proximally we advance into 
what we thought was the abdominal aorta we then performed an angiogram 
which demonstrated a dissection plane at this point we then stopped access 
from this area. We removed the sheath and the wire and then gain access on 
the opposite groin.  At this point we then gain access to the left groin 
under palpation using Seldinger technique. 

We accessed the left common 
femoral artery and then we upgraded to a 5 French sheath.  We then 
advanced a Glidewire and a VCF catheter and performed a angiogram with 
minimal contrast.  This demonstrated extensive infrarenal calcification in 
bilateral patent common iliac arteries.  The left hypogastric appeared to 
be occluded.  The left external iliac had multilevel disease but nothing 
hemodynamically significant.  The right common iliac artery appeared to be 
patent the external had a flush occlusion about 1 cm after the takeoff.  
The left hypogastric artery appeared to be patent with an ostial lesion.  
There was extensive pelvic collaterals and reconstitution at the femoral 
head of the common femoral artery.  At this point we then upgraded to a 6 
French up-Andover sheath and advanced it over the bifurcation into the 
right common iliac artery.  We then used a support Seeker catheter within 
and a stiff 035 glidewire and was able to go through the chronic occlusion 
of the left external iliac artery into our endarterectomy site in the 
right common femoral artery.  We then switched snared the Glidewire 
through the right common femoral artery endarterectomy site. At this point 
we then placed a 6 French sheath through the Glidewire in the right groin 
and then we used a 8 x 60 mustang balloon used to measure the length of 
our occlusion.  At this point we then decided to use a 8 x 60 self 
expanding stent. We deployed the stent in standard fashion at the takeoff 
of the hypogastric artery with the endpoint proximal to the femoral head.  
We then post dilated with a 8 x 60 mustang balloon.  Postop angiogram 
demonstrated good apposition of the stent with no hemodynamic significant 
stenosis noted. We then at that point, performed a patch angioplasty with 
a pericardial patch with 6 0 Prolene in standard fashion. Before 
completing the patch angioplasty we forward flushed and backflushed the 
common femoral artery.  Before completing the full angioplasty, we left 
the wire in place and then performed a angiogram which demonstrated 
patency of the right common iliac artery as well as external iliac artery 
and common femoral artery with no hemodynamic significant stenosis.  The 
right groin shot demonstrated patency of the profundus as well as the SFA. 


 At that point we then finished our patch angioplasty and endarterectomy 
site. Everything was noted to be hemostatic and mildly oozy.  We reversed 
the patient with protamine.  We dried out any bleeding points with Bovie 
electrocautery and clips.  We then closed the right groin in layers of 
Vicryl multiple.  We closed that the subdermal with 3 0 Vicryl pop offs 
and the skin with 4 O Monocryl subcuticular stitches. Sterile dressing was 
then applied. 

On the left groin we downsized to a 6 French sheath over the 
wire under fluoroscopic guidance.  We then used a 6 French Mynx closure 
device and closed the left common femoral artery at the access site.  In 
standard fashion. Sterile dressing was then applied. At completion of the 
procedure the patient had a palpable right pedal pulses.  Patient tolerated 
the procedure well was extubated transferred to the PACU in stable 
condition.


----------



## Jim Pawloski (May 7, 2018)

dkhclement said:


> Hello - We would love someone to review our codes and provide feedback.  Also, specifically, it's our understanding that we code for both access sites, hence the use of 36140-XS-RT.  Yes/No - Circumstantial?  We are specifically being asked why we want to use this code.
> 
> These are the codes we want to use for this inpatient Medicare pt.
> 35371-RT
> ...





 I agree with 35371-RT, 37221-RT, however I would code 36245-RT,59 for the selective right iliac from the left because catheter placement codes go away because of the intervention. Also I would not charge 75630 because the renals were not imaged, but code 75710-RT for that imaging.
HTH,
Jim Pawloski, CIRCC


----------

