mfournier
Networker
Hello Everyone:
Can anyone guide me as to roughly what cpt code this should be? Looking in the "Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease cpt 35001-35152 but there is no tibial artery repair and this pt does not have occlusive disease.
Indications: The patient is a 23-year-old gentleman who suffered a stab injury to his right lower extremity about 4 to 5 weeks ago. He was evaluated at an outside facility, and it appears that he underwent primary repair of his stab wound. He presented to our hospital 2 days ago with persistent nonhealing and breakdown of the previous incision, and anecdotally reported several episodes of what appears to be arterial bleeding. He was found to be significantly anemic with a hemoglobin of 7, and underwent a blood transfusion. A CT angiogram of his right leg was performed demonstrating a large pseudoaneurysm arising from the proximal right anterior tibial artery. He was offered open repair to prevent further risk of hemorrhage.
Findings: Large pseudoaneurysm cavity, with a 15 mm defect in the medial aspect of the proximal anterior tibial artery. The right great saphenous vein appeared suitable for an autogenous conduit.
Narrative: The patient was brought into the operating theater and placed supine. Preoperative timeout was performed. After general anesthesia, a Foley catheter was placed. The right lower extremity was circumferentially prepped and draped in the usual sterile fashion. Given the proximity to the proximal anterior tibial artery, I elected to proceed with endovascular control. Using ultrasound guidance the right common femoral artery was accessed in antegrade fashion using a micro puncture kit, and a 5 French sheath placed. Using an angled taper catheter I was able to cannulate the right anterior tibial artery, and an angiogram was performed to delineate the large area of contained extravasation. I passed a V 18 wire distally, and used a 3 mm balloon, and inflated it for arterial control. The patient was then given systemic heparin.
I then made a longitudinal incision in the lateral aspect of the right leg and deepened to the soft tissue with cautery. I split the fibers of the anterior compartment and dissected down until identified the proximal anterior tibial artery. It was encircled with a vessel loop. I then extended my incision distally towards the mid part of the leg. We entered the pseudoaneurysm cavity, and evacuated the mural thrombus. With some difficulty I was able to dissect out the normal healthy appearing anterior tibial artery distal to the pseudoaneurysm cavity. Once I had proximal distal control I was able to better visualize the defect in the medial aspect of anterior tibial artery. This was clearly not amenable to primary repair. I elected to replace it with an interposition graft.
I then made a longitudinal incision on the medial aspect of the right knee and deepened into the soft tissue with the cautery. The great saphenous vein identified this location and appear to be of suitable size. It was mobilized for several centimeters proximally distally. The proximal distal ends were ligated, the vein transected and set aside in a heparin solution. I then deflated the balloon, and placed clamps proximal distal to the defect. The lacerated segment of the artery was transected and removed. The proximal and distal ends were spatulated. We brought on the saphenous vein graft onto the field, and oriented it in a reversed fashion. The proximal aspect of the vein graft was spatulated and end-to-end anastomosis was created to the proximal anterior tibial artery using running 7-0 Prolene. The vein graft was flushed, reclamped, and trimmed to length. The distal end of the vein graft was spatulated, and end-to-end anastomosis was created to the distal stump of the anterior tibial artery using running 7-0 Prolene. The distal stump of the artery was interrogated using a coronary dilator, flushing maneuvers were performed, and the anastomosis completed and noted to be hemostatic. There is a palpable pulse throughout the short segment of vein graft as well as in the native artery distal to this.
I then performed a completion angiogram through the sheath in the right common femoral artery demonstrating what appeared to be a patent proximal distal anastomosis with significant vasospasm proximally as well as distally beyond the anastomosis. I then crossed the bypass graft using my V 18 wire again, and brought in a 3 mm balloon to perform balloon angioplasty. After deflating it, I shot a completion angiogram once again demonstrating better flow proximally, but significant vasospasm the long segment stenosis just distal to the angioplasty site. I again advanced my balloon somewhat further distally and reinflated it again. I suspected his young age made him particularly susceptible to vasospasm with the extensive dissection necessary. Repeat angiography continued demonstrate significant vasospasm throughout the artery particularly distal to this. There is reconstitution of the distal anterior tibial artery into the dorsalis pedis artery. At this point elected to observe this for the time being. All wires and catheters were removed, and the sheath flushed with heparinized saline.
The fascia overlying the right anterior compartment was reapproximated using running 3-0 Vicryl. The skin was closed with staples. The medial knee incision was closed with 3-0 Vicryl and skin clips. The wound overlying the anterior aspect of the right leg was packed with iodoform gauze. The right femoral sheath was removed, and Angio-Seal device was used for hemostasis.
Thanks in advance
MF
Can anyone guide me as to roughly what cpt code this should be? Looking in the "Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease cpt 35001-35152 but there is no tibial artery repair and this pt does not have occlusive disease.
Indications: The patient is a 23-year-old gentleman who suffered a stab injury to his right lower extremity about 4 to 5 weeks ago. He was evaluated at an outside facility, and it appears that he underwent primary repair of his stab wound. He presented to our hospital 2 days ago with persistent nonhealing and breakdown of the previous incision, and anecdotally reported several episodes of what appears to be arterial bleeding. He was found to be significantly anemic with a hemoglobin of 7, and underwent a blood transfusion. A CT angiogram of his right leg was performed demonstrating a large pseudoaneurysm arising from the proximal right anterior tibial artery. He was offered open repair to prevent further risk of hemorrhage.
Findings: Large pseudoaneurysm cavity, with a 15 mm defect in the medial aspect of the proximal anterior tibial artery. The right great saphenous vein appeared suitable for an autogenous conduit.
Narrative: The patient was brought into the operating theater and placed supine. Preoperative timeout was performed. After general anesthesia, a Foley catheter was placed. The right lower extremity was circumferentially prepped and draped in the usual sterile fashion. Given the proximity to the proximal anterior tibial artery, I elected to proceed with endovascular control. Using ultrasound guidance the right common femoral artery was accessed in antegrade fashion using a micro puncture kit, and a 5 French sheath placed. Using an angled taper catheter I was able to cannulate the right anterior tibial artery, and an angiogram was performed to delineate the large area of contained extravasation. I passed a V 18 wire distally, and used a 3 mm balloon, and inflated it for arterial control. The patient was then given systemic heparin.
I then made a longitudinal incision in the lateral aspect of the right leg and deepened to the soft tissue with cautery. I split the fibers of the anterior compartment and dissected down until identified the proximal anterior tibial artery. It was encircled with a vessel loop. I then extended my incision distally towards the mid part of the leg. We entered the pseudoaneurysm cavity, and evacuated the mural thrombus. With some difficulty I was able to dissect out the normal healthy appearing anterior tibial artery distal to the pseudoaneurysm cavity. Once I had proximal distal control I was able to better visualize the defect in the medial aspect of anterior tibial artery. This was clearly not amenable to primary repair. I elected to replace it with an interposition graft.
I then made a longitudinal incision on the medial aspect of the right knee and deepened into the soft tissue with the cautery. The great saphenous vein identified this location and appear to be of suitable size. It was mobilized for several centimeters proximally distally. The proximal distal ends were ligated, the vein transected and set aside in a heparin solution. I then deflated the balloon, and placed clamps proximal distal to the defect. The lacerated segment of the artery was transected and removed. The proximal and distal ends were spatulated. We brought on the saphenous vein graft onto the field, and oriented it in a reversed fashion. The proximal aspect of the vein graft was spatulated and end-to-end anastomosis was created to the proximal anterior tibial artery using running 7-0 Prolene. The vein graft was flushed, reclamped, and trimmed to length. The distal end of the vein graft was spatulated, and end-to-end anastomosis was created to the distal stump of the anterior tibial artery using running 7-0 Prolene. The distal stump of the artery was interrogated using a coronary dilator, flushing maneuvers were performed, and the anastomosis completed and noted to be hemostatic. There is a palpable pulse throughout the short segment of vein graft as well as in the native artery distal to this.
I then performed a completion angiogram through the sheath in the right common femoral artery demonstrating what appeared to be a patent proximal distal anastomosis with significant vasospasm proximally as well as distally beyond the anastomosis. I then crossed the bypass graft using my V 18 wire again, and brought in a 3 mm balloon to perform balloon angioplasty. After deflating it, I shot a completion angiogram once again demonstrating better flow proximally, but significant vasospasm the long segment stenosis just distal to the angioplasty site. I again advanced my balloon somewhat further distally and reinflated it again. I suspected his young age made him particularly susceptible to vasospasm with the extensive dissection necessary. Repeat angiography continued demonstrate significant vasospasm throughout the artery particularly distal to this. There is reconstitution of the distal anterior tibial artery into the dorsalis pedis artery. At this point elected to observe this for the time being. All wires and catheters were removed, and the sheath flushed with heparinized saline.
The fascia overlying the right anterior compartment was reapproximated using running 3-0 Vicryl. The skin was closed with staples. The medial knee incision was closed with 3-0 Vicryl and skin clips. The wound overlying the anterior aspect of the right leg was packed with iodoform gauze. The right femoral sheath was removed, and Angio-Seal device was used for hemostasis.
Thanks in advance
MF