sslater
Networker
I was given this Op note to code and am not very familiar with these procedures... could someone look at this and help?? thanks!!!
i know the Iliac ptca and stenting are in the new vascular codes, just not sure about the abd aortic stent graft.. thanks again!!
PREOPERATIVE DIAGNOSES:
1. Abdominal aortic aneurysm.
2. Left iliac artery stenosis.
POSTOPERATIVE DIAGNOSES:
1. Abdominal aortic aneurysm.
2. Left iliac artery stenosis.
OPERATIVE PROCEDURES:
1. Abdominal aortic stent graft.
2. Angioplasty, left iliac artery.
3. Angioplasty and stenting, right external iliac artery.
HISTORY: The patient is a 49-year-old gentleman known to have
abdominal aortic aneurysm. He has been increasing in size over
the last several years. He is also known to have some vascular
disease based on his CTA workup. In light of this he was worked
up for a potential endovascular procedure and was felt to be a
reasonable candidate for it. He is brought to the OR at this
time.
PROCEDURE: The patient was brought in the operating room, placed
in the supine position, and underwent induction of general
endotracheal anesthesia. The patient was then positioned,
prepped, and draped in the routine sterile fashion.
Initial step was to place an 8-French left femoral catheter
percutaneously. This was placed. C-arm showed good tracking of
the device; although, we did have a little problem negotiating
the guidewire past the stenosis at the proximal iliac artery.
Once this was done the right groin incision was made in a
transverse fashion just above the inguinal ligament. The femoral
artery was exposed for an adequate length of two clips proximally
and distally. Note was made of heavy calcification in the right
femoral artery.
At this point the decision was made to do an additional
dilatation of the left iliac artery stenosis. A 7 x 40 mm Rival
balloon was then passed up a guidewire in the left iliac artery
up to the area of stenosis right at the bifurcation. This area
was successfully dilated. Once we did this, a guidewire was
passed up the right femoral artery sticking it first in an 18-
gauge needle, advancing a glidewire up into the proximal thoracic
aorta. Over this we placed a 6-French sheath. A 6-French sheath
was passed initially so we could pass a pigtail catheter up the
right femoral artery into the proximal abdominal aorta where an
aortogram was done. This was done specifically to assess the
length of the right iliac artery. It was found that the common
iliac artery on the right was about a 3.5 cm vessel so we decided
to go with a 70-30 28 main body device. Once we had done the
arteriogram the 6-French sheath was removed and a 9-French peel-
away sheath placed up the right femoral artery. Through this
sheath we passed the contra-limb guidewire from the Endologix
device. Snare was placed up the left groin. Its wire was
grabbed and pulled back through the left 8-French sheath. Once
we had gotten this in order pressure was applied to the right
femoral artery and the 9-French peel-away sheath was removed. The
main body was then passed over the Meier wire and advanced up
into the femoral artery. We did have some problems doing this
and the initial pass was unsuccessful. The main body of the
device was removed and a dilator was used to advance up over the
wire to open up the artery some. Once we had done this we were
able then to get the main body over the Meier wire. As we
advanced the main body the contralateral wire was advanced,
pulled back up through the left groin sheath as it advanced. Once
we got in position care was taken to ensure that the guidewire
was in the right orientation.
At this point the main body device was unsheathed using a pin and
pull technique on the main body introducer device. Once this was
done the device was pulled back and anchored at the bifurcation
pulling back on the device and the contralateral limb wire. At
this point then a 0.014 guidewire was passed up the left limb
guidewire into the proximal thoracic aorta alongside the Meier
wire. Just before anchoring the device on the bifurcation the
device was unsheathed so that we could pull it down the
bifurcation and anchor it. Having done this the integrated
sheath deploying the ellipse out of the limb was retracted and
the entire limb opened up nicely. At this point a pigtail
catheter was passed up the left guidewire up to above the renal
arteries and another aortogram done. This was done to identify
the origin of the renal arteries. Once they were ascertained and
marked the aortic extension was brought up and advanced up the
right Meier wire introducer. The device here used was a 34-34-
120 suprarenal proximal device. Locating it just at the renal
arteries pin pull technique was slowly but deliberately done to
anchor the proximal extension just at the renal arteries. The
end result actually looked quite good.
At this point a Reliant balloon was used to first dilate the
overlapped area of the grafts and then the second application
done at the renal arteries to anchor this device there. A 12 x 4
balloon then went up past the contra side to dilate the graft up
to the area of the iliac stenosis. This worked out quite nicely.
At this point a completion arteriogram was done. When this was
done we identified a fairly tight-looking 89% lesion about a
centimeter distal to the right limb. This was not seen on
previous arteriogram and was likely produced as we advanced the
device up this very diseased aorta. Once we identified this as a
problem a 7 mm x 4 balloon was then used to pre-dilate this area.
This was done successfully and because of the degree of disease
in the aorta and iliac artery a decision was made to place a
stent in this area. A self-expanding 9 x 40 stent was chosen.
This was placed. This was then post-dilated with a 9 x 40
balloon. Completion angiogram showed excellent result in this
area. Note was made at this point on the arteriogram that there
was some concern about the internal iliac arteries bilaterally.
We could see some vessel feeding the pelvis but on the
arteriogram there was some concern that potentially the internal
iliacs on both sides had become occluded. There was nothing at
this point to do but again we did see flow into the pelvis via
what appeared like more distal vessels. The right internal iliac
artery seemed to opacify very lightly but there was some concern
this probably was compromised.
At this point the sheath was removed from the right femoral
artery and attempts were made at closing this using interrupted 6-
0 Prolene sutures. Angiogram was done by pulling the pigtail
down to the aortic bifurcation and doing a run. The area of the
closure appeared to be fairly stenotic in the range of at least
75-80%. Accordingly the decision was made to go ahead and take
this down. A long endarterectomy was done and carried up under
the inguinal ligament proximally and distally down to an area
just above the profunda takeoff, which was quite distal on the
right groin. We were able to tack up a fairly pronounced intimal
edge distally using interrupted 6-0 Prolene sutures. Having done
this the arteriotomy closure itself was done using a patch onlay
technique using Bovine pericardial patch. This was placed using
running 5-0 Prolene. Once this was completed the clamps were
released. Actually had good pulse distal to the graft. The
completion arteriogram was again done and a good result was noted.
At this point we had giving Heparin at the dose of about 2500
every hour. We partially reversed the Heparin at this point
around the ACT. The right groin once it was dry was irrigated
and closed using 3-0 Vicryl deep and a running subcuticular 4-0
Vicryl on the skin. A Mynx device was used to close the left
femoral artery percutaneously.
At the termination of the procedure pulses were present by
Doppler bilaterally. The patient was then extubated and taken to
the recovery room having tolerated the procedure well. Sponge
and needle count correct x2.
i know the Iliac ptca and stenting are in the new vascular codes, just not sure about the abd aortic stent graft.. thanks again!!
PREOPERATIVE DIAGNOSES:
1. Abdominal aortic aneurysm.
2. Left iliac artery stenosis.
POSTOPERATIVE DIAGNOSES:
1. Abdominal aortic aneurysm.
2. Left iliac artery stenosis.
OPERATIVE PROCEDURES:
1. Abdominal aortic stent graft.
2. Angioplasty, left iliac artery.
3. Angioplasty and stenting, right external iliac artery.
HISTORY: The patient is a 49-year-old gentleman known to have
abdominal aortic aneurysm. He has been increasing in size over
the last several years. He is also known to have some vascular
disease based on his CTA workup. In light of this he was worked
up for a potential endovascular procedure and was felt to be a
reasonable candidate for it. He is brought to the OR at this
time.
PROCEDURE: The patient was brought in the operating room, placed
in the supine position, and underwent induction of general
endotracheal anesthesia. The patient was then positioned,
prepped, and draped in the routine sterile fashion.
Initial step was to place an 8-French left femoral catheter
percutaneously. This was placed. C-arm showed good tracking of
the device; although, we did have a little problem negotiating
the guidewire past the stenosis at the proximal iliac artery.
Once this was done the right groin incision was made in a
transverse fashion just above the inguinal ligament. The femoral
artery was exposed for an adequate length of two clips proximally
and distally. Note was made of heavy calcification in the right
femoral artery.
At this point the decision was made to do an additional
dilatation of the left iliac artery stenosis. A 7 x 40 mm Rival
balloon was then passed up a guidewire in the left iliac artery
up to the area of stenosis right at the bifurcation. This area
was successfully dilated. Once we did this, a guidewire was
passed up the right femoral artery sticking it first in an 18-
gauge needle, advancing a glidewire up into the proximal thoracic
aorta. Over this we placed a 6-French sheath. A 6-French sheath
was passed initially so we could pass a pigtail catheter up the
right femoral artery into the proximal abdominal aorta where an
aortogram was done. This was done specifically to assess the
length of the right iliac artery. It was found that the common
iliac artery on the right was about a 3.5 cm vessel so we decided
to go with a 70-30 28 main body device. Once we had done the
arteriogram the 6-French sheath was removed and a 9-French peel-
away sheath placed up the right femoral artery. Through this
sheath we passed the contra-limb guidewire from the Endologix
device. Snare was placed up the left groin. Its wire was
grabbed and pulled back through the left 8-French sheath. Once
we had gotten this in order pressure was applied to the right
femoral artery and the 9-French peel-away sheath was removed. The
main body was then passed over the Meier wire and advanced up
into the femoral artery. We did have some problems doing this
and the initial pass was unsuccessful. The main body of the
device was removed and a dilator was used to advance up over the
wire to open up the artery some. Once we had done this we were
able then to get the main body over the Meier wire. As we
advanced the main body the contralateral wire was advanced,
pulled back up through the left groin sheath as it advanced. Once
we got in position care was taken to ensure that the guidewire
was in the right orientation.
At this point the main body device was unsheathed using a pin and
pull technique on the main body introducer device. Once this was
done the device was pulled back and anchored at the bifurcation
pulling back on the device and the contralateral limb wire. At
this point then a 0.014 guidewire was passed up the left limb
guidewire into the proximal thoracic aorta alongside the Meier
wire. Just before anchoring the device on the bifurcation the
device was unsheathed so that we could pull it down the
bifurcation and anchor it. Having done this the integrated
sheath deploying the ellipse out of the limb was retracted and
the entire limb opened up nicely. At this point a pigtail
catheter was passed up the left guidewire up to above the renal
arteries and another aortogram done. This was done to identify
the origin of the renal arteries. Once they were ascertained and
marked the aortic extension was brought up and advanced up the
right Meier wire introducer. The device here used was a 34-34-
120 suprarenal proximal device. Locating it just at the renal
arteries pin pull technique was slowly but deliberately done to
anchor the proximal extension just at the renal arteries. The
end result actually looked quite good.
At this point a Reliant balloon was used to first dilate the
overlapped area of the grafts and then the second application
done at the renal arteries to anchor this device there. A 12 x 4
balloon then went up past the contra side to dilate the graft up
to the area of the iliac stenosis. This worked out quite nicely.
At this point a completion arteriogram was done. When this was
done we identified a fairly tight-looking 89% lesion about a
centimeter distal to the right limb. This was not seen on
previous arteriogram and was likely produced as we advanced the
device up this very diseased aorta. Once we identified this as a
problem a 7 mm x 4 balloon was then used to pre-dilate this area.
This was done successfully and because of the degree of disease
in the aorta and iliac artery a decision was made to place a
stent in this area. A self-expanding 9 x 40 stent was chosen.
This was placed. This was then post-dilated with a 9 x 40
balloon. Completion angiogram showed excellent result in this
area. Note was made at this point on the arteriogram that there
was some concern about the internal iliac arteries bilaterally.
We could see some vessel feeding the pelvis but on the
arteriogram there was some concern that potentially the internal
iliacs on both sides had become occluded. There was nothing at
this point to do but again we did see flow into the pelvis via
what appeared like more distal vessels. The right internal iliac
artery seemed to opacify very lightly but there was some concern
this probably was compromised.
At this point the sheath was removed from the right femoral
artery and attempts were made at closing this using interrupted 6-
0 Prolene sutures. Angiogram was done by pulling the pigtail
down to the aortic bifurcation and doing a run. The area of the
closure appeared to be fairly stenotic in the range of at least
75-80%. Accordingly the decision was made to go ahead and take
this down. A long endarterectomy was done and carried up under
the inguinal ligament proximally and distally down to an area
just above the profunda takeoff, which was quite distal on the
right groin. We were able to tack up a fairly pronounced intimal
edge distally using interrupted 6-0 Prolene sutures. Having done
this the arteriotomy closure itself was done using a patch onlay
technique using Bovine pericardial patch. This was placed using
running 5-0 Prolene. Once this was completed the clamps were
released. Actually had good pulse distal to the graft. The
completion arteriogram was again done and a good result was noted.
At this point we had giving Heparin at the dose of about 2500
every hour. We partially reversed the Heparin at this point
around the ACT. The right groin once it was dry was irrigated
and closed using 3-0 Vicryl deep and a running subcuticular 4-0
Vicryl on the skin. A Mynx device was used to close the left
femoral artery percutaneously.
At the termination of the procedure pulses were present by
Doppler bilaterally. The patient was then extubated and taken to
the recovery room having tolerated the procedure well. Sponge
and needle count correct x2.