schmsuz
Guest
Could someone help with this AAA repair? I think the only thing I can bill is 34705. Can I bill either of the extensions? An 11F sheath was used so 34713 isn't appropriate, correct? Thank you!
PROCEDURES:
1. General anesthesia.
2. Right and left common femoral arterial access.
3. Right and left common femoral angiography.
4. Right femoral pre-closure with ProGlide suture devices x2.
5. Left femoral arterial cut down with endarterectomy repair by Dr. xxx(see separate surgical procedure notes).
6. Descending aortography with pelvic run-off.
7. Abdominal aortic aneurysm repair utilizing left femoral bifurcated stent graft deployment, left ipsilateral with Endurant II stent graft bifurcated system.
8. Left limb extension to cover the left common iliac artery aneurysm, Medtronic Endurant II (placed into the short limb of the bifurcated graft from the left access site).
9. Right limb extension/Medtronic Endurant II via the right common femoral artery.
10. Additional right and left iliac angiography for measurement of the limb extension grafts.
11. Reliant balloon percutaneous transluminal angioplasty post-procedure.
12. Post repair descending aortography with selective right and left iliac angiography.
13. ProGlide suture closure right common femoral artery.
*
EQUIPMENT UTILIZED:
1. Medtronic, Endurant II, bifurcated graft, ESBF3214C103E, serial #V07874717 (left ipsilateral).
2. Left limb extension, Medtronic Endurant II, ETLW1613C199E, serial #V078939133.
3. Right limb extension, Medtronic, Endurant II, ETLW1620C93E, serial #V07842850.
*
PROCEDURE IN DETAIL: The patient was brought to the catheterization laboratory. He was prepared per protocol for potential need for surgical intervention. General anesthesia was utilized without difficulties with intubation. The right and left common femoral arteries were both easily entered utilizing micropuncture technique. Despite tortuosity of the iliac systems, the guidewire passed into the central aorta. The right common femoral access site was "pre-closed" with 2 separate ProGlide suture closures at orthogonal angles. There were difficulties in passing the ProGlide suture closure systems into the left femoral region secondary to tortuosity of the system. A larger 11-French sheath system was introduced without significant improvement. A stiffer guidewire was then utilized. The ProGlide suture closures were deployed with some difficulties. The guidewire entered into a side branch and could not be retrieved into the central common femoral artery. A decision was made because of the known complexity and calcification of the femoral artery system to proceed with a surgical cut down. This was performed uneventfully by Dr. xxx and additional needle arterial access was achieved at the superior margin of the common femoral artery. The AAA repair continued uneventfully. Descending aortography was performed with a marker pigtail from the left access site. After additional confirmatory measurements were performed, the bifurcated stent graft system was positioned at the renal arteries and deployed. There were some difficulties in rotating the endograft stent system because of the marked tortuosity in the iliac system. In addition, because of the large aneurysm, there were additional difficulties in achieving right contralateral wire access into the "gate." A conscious decision was made to utilize and access from the left common femoral artery into the shorter of the 2 limbs from the bifurcated graft system. This was performed uneventfully. Additional left iliac angiography was performed with a marker pigtail. The left limb extension was placed from the bifurcated short limb into the external iliac artery. This completely covered the left common iliac artery aneurysm. The left internal iliac artery was identified as completely occluded by the previously placed Amplatzer vascular plug. Attention was then directed to the right limb. Additional iliac angiography was performed with a marker pigtail. The third graft system was placed uneventfully. A Reliant balloon system was utilized with standard PTA techniques throughout the entire stent graft system from both the right and left limbs. Post-procedure angiography was performed with descending aortography and sequential injections into the left and right iliac systems. There was good positioning of the stent graft device and no evidence for any endovascular leaks. The right sheaths were removed and the pre-closure devices were deployed with good hemostasis and palpable distal pulses. The patient received heparin throughout the procedure and this was monitored with ACTs. Attention was then directed to the surgical repair of the left common femoral artery. Ultimately, Dr. xxx made a decision because of the extensiveness of atherosclerosis to perform an endarterectomy and utilize a "carotid" patch closure system. There was a good surgical result with distal palpable pulses. The patient was extubated in the room and transferred for routine post-procedural care.
*
DESCENDING AORTOGRAPHY (POST-DEPLOYMENT): The device was positioned at the renal arteries. There was wide patency of both renal arteries and the celiac and superior mesenteric artery. There was no evidence for any endovascular leaks. There was distal flow at the stent graft margins.
*
CONCLUSIONS:
1. Successful and uneventful repair of a complex abdominal aortic aneurysm and left common iliac artery aneurysm as described above requiring a three-piece Medtronic Endurant II system.
2. Percutaneous access and closure on the right common femoral site.
3. Left surgical cut down with endarterectomy repair for the left common femoral access site.
PROCEDURES:
1. General anesthesia.
2. Right and left common femoral arterial access.
3. Right and left common femoral angiography.
4. Right femoral pre-closure with ProGlide suture devices x2.
5. Left femoral arterial cut down with endarterectomy repair by Dr. xxx(see separate surgical procedure notes).
6. Descending aortography with pelvic run-off.
7. Abdominal aortic aneurysm repair utilizing left femoral bifurcated stent graft deployment, left ipsilateral with Endurant II stent graft bifurcated system.
8. Left limb extension to cover the left common iliac artery aneurysm, Medtronic Endurant II (placed into the short limb of the bifurcated graft from the left access site).
9. Right limb extension/Medtronic Endurant II via the right common femoral artery.
10. Additional right and left iliac angiography for measurement of the limb extension grafts.
11. Reliant balloon percutaneous transluminal angioplasty post-procedure.
12. Post repair descending aortography with selective right and left iliac angiography.
13. ProGlide suture closure right common femoral artery.
*
EQUIPMENT UTILIZED:
1. Medtronic, Endurant II, bifurcated graft, ESBF3214C103E, serial #V07874717 (left ipsilateral).
2. Left limb extension, Medtronic Endurant II, ETLW1613C199E, serial #V078939133.
3. Right limb extension, Medtronic, Endurant II, ETLW1620C93E, serial #V07842850.
*
PROCEDURE IN DETAIL: The patient was brought to the catheterization laboratory. He was prepared per protocol for potential need for surgical intervention. General anesthesia was utilized without difficulties with intubation. The right and left common femoral arteries were both easily entered utilizing micropuncture technique. Despite tortuosity of the iliac systems, the guidewire passed into the central aorta. The right common femoral access site was "pre-closed" with 2 separate ProGlide suture closures at orthogonal angles. There were difficulties in passing the ProGlide suture closure systems into the left femoral region secondary to tortuosity of the system. A larger 11-French sheath system was introduced without significant improvement. A stiffer guidewire was then utilized. The ProGlide suture closures were deployed with some difficulties. The guidewire entered into a side branch and could not be retrieved into the central common femoral artery. A decision was made because of the known complexity and calcification of the femoral artery system to proceed with a surgical cut down. This was performed uneventfully by Dr. xxx and additional needle arterial access was achieved at the superior margin of the common femoral artery. The AAA repair continued uneventfully. Descending aortography was performed with a marker pigtail from the left access site. After additional confirmatory measurements were performed, the bifurcated stent graft system was positioned at the renal arteries and deployed. There were some difficulties in rotating the endograft stent system because of the marked tortuosity in the iliac system. In addition, because of the large aneurysm, there were additional difficulties in achieving right contralateral wire access into the "gate." A conscious decision was made to utilize and access from the left common femoral artery into the shorter of the 2 limbs from the bifurcated graft system. This was performed uneventfully. Additional left iliac angiography was performed with a marker pigtail. The left limb extension was placed from the bifurcated short limb into the external iliac artery. This completely covered the left common iliac artery aneurysm. The left internal iliac artery was identified as completely occluded by the previously placed Amplatzer vascular plug. Attention was then directed to the right limb. Additional iliac angiography was performed with a marker pigtail. The third graft system was placed uneventfully. A Reliant balloon system was utilized with standard PTA techniques throughout the entire stent graft system from both the right and left limbs. Post-procedure angiography was performed with descending aortography and sequential injections into the left and right iliac systems. There was good positioning of the stent graft device and no evidence for any endovascular leaks. The right sheaths were removed and the pre-closure devices were deployed with good hemostasis and palpable distal pulses. The patient received heparin throughout the procedure and this was monitored with ACTs. Attention was then directed to the surgical repair of the left common femoral artery. Ultimately, Dr. xxx made a decision because of the extensiveness of atherosclerosis to perform an endarterectomy and utilize a "carotid" patch closure system. There was a good surgical result with distal palpable pulses. The patient was extubated in the room and transferred for routine post-procedural care.
*
DESCENDING AORTOGRAPHY (POST-DEPLOYMENT): The device was positioned at the renal arteries. There was wide patency of both renal arteries and the celiac and superior mesenteric artery. There was no evidence for any endovascular leaks. There was distal flow at the stent graft margins.
*
CONCLUSIONS:
1. Successful and uneventful repair of a complex abdominal aortic aneurysm and left common iliac artery aneurysm as described above requiring a three-piece Medtronic Endurant II system.
2. Percutaneous access and closure on the right common femoral site.
3. Left surgical cut down with endarterectomy repair for the left common femoral access site.