jdibble
True Blue
I always get confused with these procedures done in arteries as to what is being done and what CPT codes to use. If someone could look at the OP note below and help me with the codes for what was done I would appreciate it! Also if anyone knows of a source I can turn to so I can understand these procedures or any guidance on what I am looking at that would be appreciated too!
Preoperative Diagnosis
Ischemia right lower extremity secondary to arterial occlusion, compartment syndrome, probable endocarditis with vegetation and sepsis
Postoperative Diagnosis
Same
Procedure Performed
Right popliteal tibial exploration with directed thrombectomy of trifurcation vessels, 4 compartment fasciotomy
The patient was taken the operating room after the induction of satisfactory general LMA anesthesia was prepped and draped in usual fashion the supine position. An incision was created along the lateral aspect of the leg below the knee to approximately mid calf. Using long Metzenbaum scissors the fascia of the lateral and posterior compartments were identified and using 2 passes opened along the fascia through both the incision and beneath the skin distally. Manual dilatation assured that these were open to the ankle and up to the level of the knee. The muscle did bulge out but did seem slightly dusky. Attention was then turned the medial portion of the leg an incision was created from the knee down to 1 cord away to the medial malleolus. The fascia is of the medial deep compartments were then identified and opened along their length. The popliteal artery was identified and carefully dissected away from the vein and the nerve. A single crossing vein required division to expose the trifurcation vessels. The anterior tibial, tibioperoneal trunk, posterior tibial and peroneal arteries were all identified and controlled with vessel loops. The patient was systemically heparinized and after 3 minutes the popliteal artery, which was pulseless and had no Doppler signals was opened transversely. There was considerable amount of spasm considering the size and internal diameter of the artery in someone of this body habitus. This was carefully explored under magnification and the vessel lumen was identified. A 3. Fogarty catheter was introduced carefully into the proximal vessel and run all the way up to 50 cm. This was brought back revealing what appeared to be some well-organized platelet rich thrombus. A 2nd run was performed with no clot restoring a good arterial flow. A as ago clamp was placed. Distally the 3 Fogarty catheter was used to selectively intubate the anterior tibial artery and the posterior tibial artery through the tibioperoneal trunk. The peroneal artery was attempted to be intubated was quite small. Platelet rich thrombus was brought from each. These measure down to 35 cm which was exactly where the dorsalis pedis and distal anterior tibial arteries with been on the foot. Both of these were irrigated with heparin saline and the transverse arteriotomy was closed with multiple interrupted 6 0 Prolene sutures. When this was released the 1st time there was not a very good distal pulse or Doppler and this was taken down and revised with what appeared to be a an area of plaque within the artery that was sewn down. After the 2nd closure there appeared to be a good Doppler and pulse in the tibioperoneal trunk and posterior tibial artery and a "pistol shot" Doppler in the anterior tibial. With hemostasis controlled the musculature over the anastomosis was closed try to keep this covered and the remaining fasciotomy incisions were packed with saline gauze. A loose bandage was applied. The patient tolerated the procedure satisfactorily and returned to ICU in stable condition with all final sponge, instrument and needle counts correct. He did have a water hammer Doppler at the posterior tibial. The concerned is that his foot vessels are thrombosed despite the tPA and there will be no outflow for his native vessels and these will thrombosed. We will have Radiology remove the arterial catheter.
Thanks for all the help I can get!!
Jodi
Preoperative Diagnosis
Ischemia right lower extremity secondary to arterial occlusion, compartment syndrome, probable endocarditis with vegetation and sepsis
Postoperative Diagnosis
Same
Procedure Performed
Right popliteal tibial exploration with directed thrombectomy of trifurcation vessels, 4 compartment fasciotomy
The patient was taken the operating room after the induction of satisfactory general LMA anesthesia was prepped and draped in usual fashion the supine position. An incision was created along the lateral aspect of the leg below the knee to approximately mid calf. Using long Metzenbaum scissors the fascia of the lateral and posterior compartments were identified and using 2 passes opened along the fascia through both the incision and beneath the skin distally. Manual dilatation assured that these were open to the ankle and up to the level of the knee. The muscle did bulge out but did seem slightly dusky. Attention was then turned the medial portion of the leg an incision was created from the knee down to 1 cord away to the medial malleolus. The fascia is of the medial deep compartments were then identified and opened along their length. The popliteal artery was identified and carefully dissected away from the vein and the nerve. A single crossing vein required division to expose the trifurcation vessels. The anterior tibial, tibioperoneal trunk, posterior tibial and peroneal arteries were all identified and controlled with vessel loops. The patient was systemically heparinized and after 3 minutes the popliteal artery, which was pulseless and had no Doppler signals was opened transversely. There was considerable amount of spasm considering the size and internal diameter of the artery in someone of this body habitus. This was carefully explored under magnification and the vessel lumen was identified. A 3. Fogarty catheter was introduced carefully into the proximal vessel and run all the way up to 50 cm. This was brought back revealing what appeared to be some well-organized platelet rich thrombus. A 2nd run was performed with no clot restoring a good arterial flow. A as ago clamp was placed. Distally the 3 Fogarty catheter was used to selectively intubate the anterior tibial artery and the posterior tibial artery through the tibioperoneal trunk. The peroneal artery was attempted to be intubated was quite small. Platelet rich thrombus was brought from each. These measure down to 35 cm which was exactly where the dorsalis pedis and distal anterior tibial arteries with been on the foot. Both of these were irrigated with heparin saline and the transverse arteriotomy was closed with multiple interrupted 6 0 Prolene sutures. When this was released the 1st time there was not a very good distal pulse or Doppler and this was taken down and revised with what appeared to be a an area of plaque within the artery that was sewn down. After the 2nd closure there appeared to be a good Doppler and pulse in the tibioperoneal trunk and posterior tibial artery and a "pistol shot" Doppler in the anterior tibial. With hemostasis controlled the musculature over the anastomosis was closed try to keep this covered and the remaining fasciotomy incisions were packed with saline gauze. A loose bandage was applied. The patient tolerated the procedure satisfactorily and returned to ICU in stable condition with all final sponge, instrument and needle counts correct. He did have a water hammer Doppler at the posterior tibial. The concerned is that his foot vessels are thrombosed despite the tPA and there will be no outflow for his native vessels and these will thrombosed. We will have Radiology remove the arterial catheter.
Thanks for all the help I can get!!
Jodi