Here is one report. I think the bypass should be billed separately, but.... I really appreciate another opinion.
Thank you.
PREOPERATIVE DIAGNOSES: EXTENT II THORACOABDOMINAL AORTIC ANEURYSM.
POSTOPERATIVE DIAGNOSES: EXTENT II THORACOABDOMINAL AORTIC ANEURYSM.
PROCEDURES PERFORMED: REPAIR OF EXTENT II THORACOABDOMINAL AORTIC ANEURYSM
(28 MM COSELLI BRANCH GRAFT ), REVASCULARIZATION OF LEFT RENAL ARTERY,
CELIAC ARTERY, SUPERIOR MESENTERIC ARTERY, 3 INTERCOSTAL ARTERIAL BYPASS
GRAFTS USING REVERSE SAPHENOUS VEIN GRAFT, ENDOSCOPIC RIGHT GREATER SAPHENOUS
VEIN HARVEST AND THERAPEUTIC ASPIRATION BRONCHOSCOPY.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine initially and induced with general endotracheal anesthesia.
A double-lumen endotracheal tube was placed and then the right lower
extremity was prepped and draped in the usual sterile fashion. The right
greater saphenous vein in the thigh was harvested endoscopically in the
usual fashion. The Incisions were closed in layers with running absorbable
suture and then the patient was turned in the right lateral decubitus
position with the table flexed. Of note, both a lumbar drain and an
epidural catheter were placed preoperatively by the Anesthesia Team, as
were a Swan-Ganz catheter and a right radial arterial line. I also placed
a right common femoral arterial line prior to turning the patient. Once
the operation was turned in the right lateral decubitus position, the left
chest, abdomen and groin were prepped and draped in the usual sterile
fashion. A sixth interspace thoracoabdominal incision was made from down
to the suprapubic level. The diaphragm was taken down circumferentially
and the entire thoracoabdominal aorta exposed. The patient was
subsequently heparinized and duly cannulated arterially. The proximal
descending thoracic aorta was cannulated with a #6 Sarns soft tip and the
terminal abdominal aorta just at the level of the bifurcation was
cannulated using an 18-French Fem-Flex femoral arterial type cannula. The
IVC-RA junction was cannulated using a 31-French right angle metal cannula.
This was accessed after a transverse pericardiotomy which was made just at
the diaphragmatic reflection posterior to the phrenic nerve, keeping the
phrenic nerve well free from harm's way. Once cannulated, the patient was
placed on cardiopulmonary bypass and systemically cooled to 28 degrees
centigrade. We monitored the patient with continuous EEG and SSEPs and
upon reaching a temperature of 28 degrees, we then placed proximal and
distal clamps in the proximal third of the descending thoracic aorta, then
maintaining dual inflow to the lower body via the abdominal aorta and the
upper body via the proximal descending thoracic aorta. We then transected
the aorta at approximately the T5 level and anastomosed a 28 mm Coselli
graft which was a 4-branch graft. After trimming it to an appropriate
length, it was anastomosed in an end-to-end fashion to the proximal
descending thoracic aorta using running 4-0 Prolene suture, taking care to
intussuscept graft into the native aorta for a hemostatic suture line.
Following its completion, we placed a distal clamp just proximal to the
aortic bifurcation and proximal to the distal perfusion inflow catheter so
that we could maintain perfusion to both hypogastrics and iliacs. We then
filleted open the entire thoracoabdominal aorta and extracted all the
luminal thrombus. We then transected the abdominal aorta level just at the
right renal artery, beveling the transected aorta to include the right
renal artery. We then trimmed the 28 mm Coselli graft to an appropriate
length and anastomosed it in an end-to-end fashion to the abdominal aorta
below the level of the left renal artery, celiac artery and superior
mesenteric artery, but incorporating the right renal artery in the distal
anastomosis. This distal anastomosis was completed with running 4-0
Prolene suture. After completing the distal graft anastomosis, we then
deaired the intervening segment and then reconstituted flow in an antegrade
fashion via the proximal descending thoracic aortic inflow and terminated
inflow from the distal inflow cannula. Of note, just prior to initiating
the distal anastomosis and after having filleted open the thoracoabdominal
aorta completely, we identified the left renal artery, celiac artery and
superior mesenteric arteries and circumferentially dissected each of these
out and created buttons for each of these vessels. We then inserted
8-French Vitalcor olive tip cannulas into each of these vessels and began
infusing cold blood at an inflow temperature of 28 degrees using the
cardioplegia circuit as a second inflow pump to facilitate perfusion of
these 3 vessels such that these 3 vessels were continuously perfused during
completion of the distal aortic anastomosis.
Next, we stapled the right renal arterial limb of the Coselli graft just at
its takeoff using an Endo-GIA stapler. We then trimmed the left renal
arterial graft which was an 8 mm branch of the Coselli graft to an
appropriate length. We transected the left renal artery at its ostium, as
the ostium itself was heavily calcified. The vessel beyond this transected
site was healthy. It was cut in a beveled fashion and then anastomosed in
an end-to-end fashion to the 8 mm side arm graft of the Coselli graft using
running 5-0 Prolene suture. Following completion, flow was reconstituted
into it.
Next, we drew attention toward revascularizing the superior mesenteric
artery. We maintained inflow through the ostial catheter. We then trimmed
the first 10-mm branch graft of the Coselli graft to an appropriate length
and anastomosed it in an end-to-end fashion to the SMA. Just prior to
completion of the anastomosis, we removed the olive tip catheter
terminating flow to it, completing the anastomosis and then reconstituted
flow into it. Finally, we trimmed the second 10 mm limb of the branch
grafts off the Coselli graft to an appropriate length and maintaining
perfusion of the celiac with the olive tip catheter, we completed the
majority of this anastomosis in an end-to-end fashion using running 5-0
Prolene suture. Just prior to its completion, the olive tip catheter was
removed and then perfusion terminated and then reconstituted flow into the
celiac. Next, we identified 3 intercostal arteries worthy of grafting.
There were two at the T8 level and one at the T12 level that were all
excellent candidates. For the two T8 intercostal arteries, we
circumferentially dissected them out, created small aortic buttons
associated with each ostium. We then first took one vein graft, reversed
it, spatulated it on one end and anastomosed it to the medial or right T8
intercostal artery using running 5-0 Prolene suture. We then made a
longitudinal venotomy of the vein graft and anastomosed it in an
end-to-side fashion to the second or left T8 intercostal artery using
running 5-0 Prolene suture. We then wrapped the vein graft around the
ascending aortic graft to reach the left anterior aspect. We mapped out on
its course to ensure no kinking. We then placed a partial occlusion clamp
on the 28 mm graft, made a circular graftotomy with the ophthalmic cautery
device, trimmed the vein graft to an appropriate length, spatulated it, and
anastomosed it to the descending thoracic aortic graft using running 5-0
Prolene suture. We de-aired the graft and then reconstituted flow through
both of these intercostals. Next, we drew our attention to the T12
intercostal artery. It was again circumferentially dissected out, an
intercostal arterial button created and then a second vein graft reversed,
spatulated, and anastomosed to the intercostal artery using running 5-0
Prolene suture. It was trimmed to an appropriate length, wrapped
anteriorly to wrap around the aortic graft, a partial occlusion clamp was
placed on the aortic graft, a circular graftotomy made with the ophthalmic
cautery device and then the vein graft cut to an appropriate length,
spatulated, and anastomosed to the aortic graft using running 5-0 Prolene
suture. We reconstituted flow into this graft.
We then began ventilating the left lung and then after the patient had
rewarmed to normothermia, she was subsequently weaned from cardiopulmonary
bypass using dual lung ventilation. The heparin was then reversed with IV
protamine. We then interrogated the intercostal grafts using the Medi-Stim
flow probe and each of the grafts had excellent flows of over 60 mL per
minute with pulse indices between 1.4 and 1.8 indicative of low resistance
excellent flow grafts. After decannulation, meticulous hemostasis was
confirmed. We then reapproximated the diaphragm using running looped #1
Maxon suture. Two 24-French Blake drains were placed in the left pleural
space. The ribs were approximated with interrupted #2 Vicryl sutures. The
serratus anterior and latissimus dorsi fascia were approximated with
running #1 Vicryl. The abdominal fascia was reapproximated with running #1
looped Maxon. The subcutaneous tissues and skin were approximated with
running absorbable sutures.
To me the renal/celiac Could possibly be billed. Next to 33877 in the CPT Book it says "other intervetional procedures at the time of the Aorta Repair should be additionally reported It says Visceral which would include (Renal)" but at the same time is CPT 33877 Open or Percutaneous???