conleyclan
Guru
Can anyone give me direction on how to decipher if this report would be coded 33880 or 33881. I always have a hard time figuring out if the first deployment is covereing the subclavian. This is pretty lengthy report. Thank you so much.
PREOPERATIVE DIAGNOSIS: Acute type B aortic dissection with malperfusion
(celiac artery, right renal artery, left renal artery, superior mesenteric
artery and right common iliac artery).
POSTOPERATIVE DIAGNOSIS: Acute type B aortic dissection with malperfusion
(celiac artery, right renal artery, left renal artery, superior mesenteric
artery and right common iliac artery).
PROCEDURE PERFORMED: Transposition left subclavian artery to left common
carotid artery. Thoracic endovascular aortic repair (Cook dissection
system: ZDEG 38 mm x 204 mm, ZDES 36 mm x 80 mm, ZDES 36 mm x 80 mm, ZDES
46 mm x 185 mm, ZDES 46 mm x 120 mm modules), thoracic aortogram with
radiologic supervision and interpretation, intravascular ultrasound with
radiologic supervision and interpretation, cutdown left common femoral
artery with primary repair.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine after the anesthesia team placed a lumbar drain for CSF
drainage. They then placed a central line and right radial arterial line
for intraoperative monitoring. He was placed supine, induced with general
endotracheal anesthesia and then he was prepped and draped in the usual
sterile fashion from the ears to the toes. We first drew our attention
toward completing the left subclavian arterial to left common carotid
arterial transposition. A 2.5 cm transverse incision was made
approximately 1/2 fingerbreadth above the left clavicle within the confines
of the sternocleidomastoid muscle. We incised the platysma transversally
and then identified the sternal and clavicular heads of the
sternocleidomastoid. They were each retracted medially and laterally,
respectively, and then we carefully dissected out the left common carotid
artery circumferentially obtaining proximal and distal control. We then
extended our dissection deeper. We identified the thoracic duct that was
kept free of injury. Inferior to the thoracic duct, we then opened the fat
pad and identified the left subclavian artery and the left vertebral
artery. The left carotid artery was circumferentially controlled and then
we obtained circumferential control of left subclavian artery and extended
that control down to its base. After a complete exposure, we then
heparinized the patient to an ACT of approximately 200-250 seconds and then
placed occlusive clamp across the proximal left subclavian artery and
distal clamps as well. We then transected the left subclavian and the
proximal stump was oversewn with running 6-0 Prolene suture. We reinforced
with a single pledgeted 5-0 Prolene suture. We then rotated and transposed
left subclavian up to the left carotid. This was done of course medial to
the left internal jugular vein. We then placed proximal and distal clamps
on the left common carotid artery (of note, we were monitoring the patient
with continuous EEG and SSEPs), and then an elliptical arteriotomy was made
on the left common carotid artery on its left posterior aspect. We then
anastomosed the left subclavian artery to the left common carotid artery in
an end-to-side fashion using running 6-0 Prolene suture. The carotid was
de-aired retrograde, the clamps were all removed and then the carotid
reperfused and the left subclavian reperfused. We subsequently reversed
the heparin temporarily, confirmed hemostasis, left that wound open and
then proceeded with dissecting out the left common femoral artery. A 2 cm
oblique incision was made above the left inguinal crease and the left
common femoral artery was dissected out circumferentially at the level of
the inguinal ligament obtaining proximal and distal control. We then
introduced an 18-gauge needle under direct vision into the left common
femoral artery and advanced the guidewire under fluoroscopic guidance up
into the abdominal aorta and then passed a guidewire up through the
thoracic aorta and into the ascending aorta. Once in position, it was
exchanged for a pigtail catheter and then that pigtail exchanged for a
Lunderquist Super Stiff guidewire. With the Lunderquist guidewire in place
with its tip in the ascending aorta, we then passed an intravascular
ultrasound probe over the guidewire and confirmed that we were in fact in
the true lumen along the entire course (of note, the left common femoral
artery was fed exclusively by the true lumen. Confirmation of the wire
being in the true lumen was first done in a retrograde fashion and then
done in an antegrade with the IVUS catheter. We then exchanged the
Lunderquist Super Stiff guidewire for a pigtail catheter and then performed
a thoracic aortogram of the aortic arch clearly mapping out the left common
carotid artery, its takeoff, the stump of the left subclavian artery, and
the proximal aspect of the dissection. We used this arteriogram as our
roadmap for the first module of stent graft deployed. For this, we chose a
38 mm x 204 mm Cook ZDEG stent graft system. We exchanged the pigtail
catheter for a Lunderquist Super Stiff guidewire and over that guidewire,
we advanced the 38 mm stent graft with its delivery system housed in a
22-French sheath was advanced into position. Respirations were held and
then the stent graft carefully deployed with the proximal most aspect of
the stent graft positioned right at the distal edge of the takeoff of the
left common carotid artery. Excellent position was obtained. The stent
graft was slowly deployed and then its tripwire found release. We then
removed the delivery system and next exchanged the 22-French Cook sheath
for a 22-French Gore DrySeal sheath again over our Lunderquist Super Stiff
guidewire. Then, we advanced a 36 mm x 80 mm Cook ZDES bare-metal stent.
This was positioned in the distal most aorta just 1 cm above the
bifurcation. The reason we deployed this first is that the caliber of the
infrarenal abdominal aorta was significantly smaller than the mesenteric
segment of the aorta and the thoracic aorta which would require a 46 mm
ZDES bare-metal stent. Therefore, we deployed the distal most stent first.
This again was a 36 mm x 80 mm bare-metal stent. It was positioned into
place and then deployed in the distal most aspect of the infrarenal
abdominal aorta. Following completion, we then deployed a second 36 mm x
80 mm bare-metal stent because the proximal most aspect of the first 36 mm
x 80 mm had slight enfolding of its proximal stent. The second piece
opened that segment. We then advanced a 46 mm x 185 mm Cook ZDES
bare-metal stent. This was positioned within the stent graft in the
descending thoracic aorta with overlap of 1-1/2 Z stents within the stent
graft. The 46 mm x 185 mm was deployed. There was a residual segment of
unstented perimesenteric aorta and along the course of approximately 8 cm
and therefore a 46 mm x 120 mm Cook ZDES bare-metal stent was deployed,
bridging the gap between the 46 mm x 185 mm and the second 36 mm x 80 mm
DES. This effectively completed and stenting the entire thoracoabdominal
aorta from the proximal stent graft in the proximal descending thoracic
aorta. We then ballooned the proximal stent graft at its proximal landing
site with a 32-mm noncompliant Coda balloon. We profiled the proximal
landing site and similarly profiled the overlapping segment of stent with
stent graft in the mid descending thoracic aorta. We did not ballooned any
of the bare-metal stents segment alone except the very distal aspect just
above the aortic bifurcation was not completely expanded and therefore a
soft ballooning was performed using a Gore trilobed balloon. Next, we
performed a completion aortogram of the aortic arch, the mesenteric and
renal segment of the aorta and the distal abdominal aorta with iliac runoff
for total of 3 completion aortograms. There was no type I endoleak or type
II endoleak of the proximal and distal landing sites of the stent graft
portion. There was a residual false lumen flow in the proximal abdominal
aorta due to a secondary tear that was present prior to stent graft
deployment, but we had good expansion of the bare-metal stents throughout
the abdominal aorta. Next, a DrySeal sheath was removed. Proximal and
distal clamps were placed on the left common femoral artery and that vessel
was repaired primarily with running 6-0 Prolene suture. Protamine was
administered to reverse heparin. We had maintained an ACT of over 200
seconds during the entire stent graft and a bare-metal stent deployment
portion of the procedure.
After confirmation of hemostasis, both the base of the neck incision and
the left groin incisions were closed in layers with running absorbable
sutures. The patient was awoken in the operating room with a normal
neurologic exam. Of note, throughout the procedure, we monitored the
patient with continuous SSEP and MEP monitoring. The patient was
subsequently extubated and transferred to the CTICU in stable condition.
PREOPERATIVE DIAGNOSIS: Acute type B aortic dissection with malperfusion
(celiac artery, right renal artery, left renal artery, superior mesenteric
artery and right common iliac artery).
POSTOPERATIVE DIAGNOSIS: Acute type B aortic dissection with malperfusion
(celiac artery, right renal artery, left renal artery, superior mesenteric
artery and right common iliac artery).
PROCEDURE PERFORMED: Transposition left subclavian artery to left common
carotid artery. Thoracic endovascular aortic repair (Cook dissection
system: ZDEG 38 mm x 204 mm, ZDES 36 mm x 80 mm, ZDES 36 mm x 80 mm, ZDES
46 mm x 185 mm, ZDES 46 mm x 120 mm modules), thoracic aortogram with
radiologic supervision and interpretation, intravascular ultrasound with
radiologic supervision and interpretation, cutdown left common femoral
artery with primary repair.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine after the anesthesia team placed a lumbar drain for CSF
drainage. They then placed a central line and right radial arterial line
for intraoperative monitoring. He was placed supine, induced with general
endotracheal anesthesia and then he was prepped and draped in the usual
sterile fashion from the ears to the toes. We first drew our attention
toward completing the left subclavian arterial to left common carotid
arterial transposition. A 2.5 cm transverse incision was made
approximately 1/2 fingerbreadth above the left clavicle within the confines
of the sternocleidomastoid muscle. We incised the platysma transversally
and then identified the sternal and clavicular heads of the
sternocleidomastoid. They were each retracted medially and laterally,
respectively, and then we carefully dissected out the left common carotid
artery circumferentially obtaining proximal and distal control. We then
extended our dissection deeper. We identified the thoracic duct that was
kept free of injury. Inferior to the thoracic duct, we then opened the fat
pad and identified the left subclavian artery and the left vertebral
artery. The left carotid artery was circumferentially controlled and then
we obtained circumferential control of left subclavian artery and extended
that control down to its base. After a complete exposure, we then
heparinized the patient to an ACT of approximately 200-250 seconds and then
placed occlusive clamp across the proximal left subclavian artery and
distal clamps as well. We then transected the left subclavian and the
proximal stump was oversewn with running 6-0 Prolene suture. We reinforced
with a single pledgeted 5-0 Prolene suture. We then rotated and transposed
left subclavian up to the left carotid. This was done of course medial to
the left internal jugular vein. We then placed proximal and distal clamps
on the left common carotid artery (of note, we were monitoring the patient
with continuous EEG and SSEPs), and then an elliptical arteriotomy was made
on the left common carotid artery on its left posterior aspect. We then
anastomosed the left subclavian artery to the left common carotid artery in
an end-to-side fashion using running 6-0 Prolene suture. The carotid was
de-aired retrograde, the clamps were all removed and then the carotid
reperfused and the left subclavian reperfused. We subsequently reversed
the heparin temporarily, confirmed hemostasis, left that wound open and
then proceeded with dissecting out the left common femoral artery. A 2 cm
oblique incision was made above the left inguinal crease and the left
common femoral artery was dissected out circumferentially at the level of
the inguinal ligament obtaining proximal and distal control. We then
introduced an 18-gauge needle under direct vision into the left common
femoral artery and advanced the guidewire under fluoroscopic guidance up
into the abdominal aorta and then passed a guidewire up through the
thoracic aorta and into the ascending aorta. Once in position, it was
exchanged for a pigtail catheter and then that pigtail exchanged for a
Lunderquist Super Stiff guidewire. With the Lunderquist guidewire in place
with its tip in the ascending aorta, we then passed an intravascular
ultrasound probe over the guidewire and confirmed that we were in fact in
the true lumen along the entire course (of note, the left common femoral
artery was fed exclusively by the true lumen. Confirmation of the wire
being in the true lumen was first done in a retrograde fashion and then
done in an antegrade with the IVUS catheter. We then exchanged the
Lunderquist Super Stiff guidewire for a pigtail catheter and then performed
a thoracic aortogram of the aortic arch clearly mapping out the left common
carotid artery, its takeoff, the stump of the left subclavian artery, and
the proximal aspect of the dissection. We used this arteriogram as our
roadmap for the first module of stent graft deployed. For this, we chose a
38 mm x 204 mm Cook ZDEG stent graft system. We exchanged the pigtail
catheter for a Lunderquist Super Stiff guidewire and over that guidewire,
we advanced the 38 mm stent graft with its delivery system housed in a
22-French sheath was advanced into position. Respirations were held and
then the stent graft carefully deployed with the proximal most aspect of
the stent graft positioned right at the distal edge of the takeoff of the
left common carotid artery. Excellent position was obtained. The stent
graft was slowly deployed and then its tripwire found release. We then
removed the delivery system and next exchanged the 22-French Cook sheath
for a 22-French Gore DrySeal sheath again over our Lunderquist Super Stiff
guidewire. Then, we advanced a 36 mm x 80 mm Cook ZDES bare-metal stent.
This was positioned in the distal most aorta just 1 cm above the
bifurcation. The reason we deployed this first is that the caliber of the
infrarenal abdominal aorta was significantly smaller than the mesenteric
segment of the aorta and the thoracic aorta which would require a 46 mm
ZDES bare-metal stent. Therefore, we deployed the distal most stent first.
This again was a 36 mm x 80 mm bare-metal stent. It was positioned into
place and then deployed in the distal most aspect of the infrarenal
abdominal aorta. Following completion, we then deployed a second 36 mm x
80 mm bare-metal stent because the proximal most aspect of the first 36 mm
x 80 mm had slight enfolding of its proximal stent. The second piece
opened that segment. We then advanced a 46 mm x 185 mm Cook ZDES
bare-metal stent. This was positioned within the stent graft in the
descending thoracic aorta with overlap of 1-1/2 Z stents within the stent
graft. The 46 mm x 185 mm was deployed. There was a residual segment of
unstented perimesenteric aorta and along the course of approximately 8 cm
and therefore a 46 mm x 120 mm Cook ZDES bare-metal stent was deployed,
bridging the gap between the 46 mm x 185 mm and the second 36 mm x 80 mm
DES. This effectively completed and stenting the entire thoracoabdominal
aorta from the proximal stent graft in the proximal descending thoracic
aorta. We then ballooned the proximal stent graft at its proximal landing
site with a 32-mm noncompliant Coda balloon. We profiled the proximal
landing site and similarly profiled the overlapping segment of stent with
stent graft in the mid descending thoracic aorta. We did not ballooned any
of the bare-metal stents segment alone except the very distal aspect just
above the aortic bifurcation was not completely expanded and therefore a
soft ballooning was performed using a Gore trilobed balloon. Next, we
performed a completion aortogram of the aortic arch, the mesenteric and
renal segment of the aorta and the distal abdominal aorta with iliac runoff
for total of 3 completion aortograms. There was no type I endoleak or type
II endoleak of the proximal and distal landing sites of the stent graft
portion. There was a residual false lumen flow in the proximal abdominal
aorta due to a secondary tear that was present prior to stent graft
deployment, but we had good expansion of the bare-metal stents throughout
the abdominal aorta. Next, a DrySeal sheath was removed. Proximal and
distal clamps were placed on the left common femoral artery and that vessel
was repaired primarily with running 6-0 Prolene suture. Protamine was
administered to reverse heparin. We had maintained an ACT of over 200
seconds during the entire stent graft and a bare-metal stent deployment
portion of the procedure.
After confirmation of hemostasis, both the base of the neck incision and
the left groin incisions were closed in layers with running absorbable
sutures. The patient was awoken in the operating room with a normal
neurologic exam. Of note, throughout the procedure, we monitored the
patient with continuous SSEP and MEP monitoring. The patient was
subsequently extubated and transferred to the CTICU in stable condition.