TWilliam2019
Guru
Procedure list in detail:
1. Bilateral iliofemoral embolectomy through bilateral femoral artery exposure
2. Left common femoral artery thromboendarterectomy with patch angioplasty
3. Bilateral popliteal and tibial artery embolectomy through bilateral popliteal artery exposure
4. Deep and superficial fasciotomy of the right lower extremity
5. Left brachial embolectomy through left brachial artery exposure
4. Left distal radial artery and palmar arch embolectomy through left radial artery exposure
*
Post-operative Diagnosis: Post-op Diagnosis
* Peripheral artery occlusion (CMS/HCC) [I77.9]
*
Indications:
Critical ischemia of the bilateral lower extremities and left hand
Findings:
See dictation below
Complications:
None
*
Procedure Details:
This is an unfortunate patient to underwent a EP lab ablation procedure for ventricular tachycardia yesterday. He developed a cold pulseless left hand which intermittently showed some improvement in color but ultimately failed conservative management with persistent cyanosis of the digits. In addition he developed right hip pain and pulseless feet bilaterally. A chronic element of disease was suspected and patient was reported to have some monophasic signals last p.m. unfortunately patient continued to show no improvement in perfusion at the pedal level with advancing ischemia particularly of the right lower extremity. Arterial duplexes showed no flow beyond the knee level in either leg with evidence of chronic disease.
*
Patient was taken to the operating room and placed in supine position. The lower extremities and left upper extremity were prepped and draped with ChloraPrep. Simultaneous bilateral oblique incisions were made in the groin area. The bilateral femoral arteries were exposed and dissected down to the origins of the deep femoral and superficial femoral arteries bilaterally. Vessel loops were positioned to use for vascular control. A transverse arteriotomy was performed of the right common femoral artery. Fogarty catheter was passed proximally and no thrombus was retrieved. Good pulsatile inflow was noted. Catheter was passed distally into the SFA and some intermittent resistance was met consistent with chronic plaque. Catheter was retrieved several times with removal of a relatively scant amount of embolus. Backbleeding was observed but was not brisk. The arteriotomy was repaired with 6-0 Prolene suture.
*
Incision was then made in the right medial calf. The fascia was opened and fasciotomies were performed of this deep and superficial compartments. The muscle was ischemic in appearance and bulged upon release of the fascia. The popliteal artery was exposed and was noted to have a pulse. The vessel was controlled and a transverse arteriotomy performed. A #2 Fogarty was passed all the way to the foot level. Several passes were made and a scant amount of bullous was removed. Backbleeding was very sluggish. Several negative passes of the Fogarty catheter were made. The transverse arteriotomy was repaired and flow established in the popliteal artery. Doppler signals were resistant and no Doppler signals were detectable at the pedal level. Findings of a relatively small volume of treatable thrombus but with extensive ischemia suggested possible massive microembolization with no reflow phenomena. At this point there were no additional options for revascularization of the right lower extremity. Additional fasciotomy in the anterolateral compartments at this point would have been futile and were not performed.
*
A transverse arteriotomy was then performed the left common femoral artery. Fogarty was passed and again a relatively small amount of thrombus was retrieved from the distal vascular bed. Proximally the Fogarty was passed and a modest amount of thrombus was retrieved from the iliac artery. Arterial inflow appeared to be adequate. The common femoral artery arteriotomy was closed with 6-0 Prolene suture.
*
The left medial calf was then excised in the popliteal artery exposed. The muscle and the left leg at this point appeared to be viable and not significantly swollen. The popliteal artery had a very weak pulse at this level. Transverse arteriotomy was performed and Fogarty passed both proximally and distally. No significant clot was retrieved proximally and very scant amount of clot was retrieved distally. The Fogarty passed to the foot level. Several negative passes were performed. Very poor backbleeding was observed. The transverse arteriotomy was closed and flow established in the popliteal artery. Due to the weak inflow will return to the left common femoral artery. The femoral artery was noted to be diseased and there was concern that the closure was further impeding flow through the area. The vessel was re-controlled and a longitudinal arteriotomy performed through the prior transverse arteriotomy. Significant obstructive plaque was encountered and a femoral endarterectomy was performed. Patch angioplasty was then performed with a bovine patch. Once the patch was completed flow was established and at least at the femoral level the signal sounded good with low resistance. Flow at the pedal level on the left however was not observed to improve and we still could not get detectable Doppler signals although the color of the left foot was improving marginally.
*
Ancef sponges and thrombin-soaked Gelfoam were applied in the incisions and attention was turned to the left arm which was already prepped and draped. A transverse incision was made at the antecubital fossa. The brachial artery was exposed and a transverse arteriotomy performed. Brachial embolectomy was performed by passing the #2 Fogarty catheter both proximally and distally. The catheter appeared to pass into the radial ulnar area distribution without much resistance down to the wrist level were obstruction was met. A significant amount of embolus was retrieved and some backbleeding was observed. Proximally no significant clot was retrieved and good inflow was observed. The transverse arteriotomy at the brachial artery was closed with Prolene suture. Palpable pulse was noted at the wrist level in the radial artery but very poor perfusion in the hand and no detectable signal in the palmar arch. A longitudinal incision was then performed in the wrist over the distal radial artery. The artery was exposed for several centimeters and was noted to be soft with a pulse that was resistant. A transverse arteriotomy was performed after controlling the vessel with aneurysm clips. Good inflow was noted. Distally a #2 Fogarty was passed into the hand with retrieval of some additional thrombus. Some backbleeding was observed. Several negative passes were made with the Fogarty. The transverse arteriotomy in the radial artery was repaired and flow reestablished. Flow was palpable in snuffbox branch of the radial artery. I could still not detectable flow in the palmar arch. The hand was showing some evidence of improved perfusion. The incisions at the radial and brachial level were closed with PDS and staples.
*
Attention was returned to the lower extremities. Sponges and thrombin-soaked Gelfoam removed. 10 flat Jackson-Pratt drains were placed in both groin incisions and the left calf incision. All of these drains were brought out through separate stab incisions. The groin incisions were closed with 3-0 PDS and 4 Monocryl. The Incision was closed with 3-0 PDS and staples. The right medial calf incision and fasciotomies were left a been and dressed with Xeroform gauze and bulky Curlex. Patient remained stable during the surgery.
are these correct?
34201 50
34203 50 51
27602 51
34101 51 lt
34111 51 lt
1. Bilateral iliofemoral embolectomy through bilateral femoral artery exposure
2. Left common femoral artery thromboendarterectomy with patch angioplasty
3. Bilateral popliteal and tibial artery embolectomy through bilateral popliteal artery exposure
4. Deep and superficial fasciotomy of the right lower extremity
5. Left brachial embolectomy through left brachial artery exposure
4. Left distal radial artery and palmar arch embolectomy through left radial artery exposure
*
Post-operative Diagnosis: Post-op Diagnosis
* Peripheral artery occlusion (CMS/HCC) [I77.9]
*
Indications:
Critical ischemia of the bilateral lower extremities and left hand
Findings:
See dictation below
Complications:
None
*
Procedure Details:
This is an unfortunate patient to underwent a EP lab ablation procedure for ventricular tachycardia yesterday. He developed a cold pulseless left hand which intermittently showed some improvement in color but ultimately failed conservative management with persistent cyanosis of the digits. In addition he developed right hip pain and pulseless feet bilaterally. A chronic element of disease was suspected and patient was reported to have some monophasic signals last p.m. unfortunately patient continued to show no improvement in perfusion at the pedal level with advancing ischemia particularly of the right lower extremity. Arterial duplexes showed no flow beyond the knee level in either leg with evidence of chronic disease.
*
Patient was taken to the operating room and placed in supine position. The lower extremities and left upper extremity were prepped and draped with ChloraPrep. Simultaneous bilateral oblique incisions were made in the groin area. The bilateral femoral arteries were exposed and dissected down to the origins of the deep femoral and superficial femoral arteries bilaterally. Vessel loops were positioned to use for vascular control. A transverse arteriotomy was performed of the right common femoral artery. Fogarty catheter was passed proximally and no thrombus was retrieved. Good pulsatile inflow was noted. Catheter was passed distally into the SFA and some intermittent resistance was met consistent with chronic plaque. Catheter was retrieved several times with removal of a relatively scant amount of embolus. Backbleeding was observed but was not brisk. The arteriotomy was repaired with 6-0 Prolene suture.
*
Incision was then made in the right medial calf. The fascia was opened and fasciotomies were performed of this deep and superficial compartments. The muscle was ischemic in appearance and bulged upon release of the fascia. The popliteal artery was exposed and was noted to have a pulse. The vessel was controlled and a transverse arteriotomy performed. A #2 Fogarty was passed all the way to the foot level. Several passes were made and a scant amount of bullous was removed. Backbleeding was very sluggish. Several negative passes of the Fogarty catheter were made. The transverse arteriotomy was repaired and flow established in the popliteal artery. Doppler signals were resistant and no Doppler signals were detectable at the pedal level. Findings of a relatively small volume of treatable thrombus but with extensive ischemia suggested possible massive microembolization with no reflow phenomena. At this point there were no additional options for revascularization of the right lower extremity. Additional fasciotomy in the anterolateral compartments at this point would have been futile and were not performed.
*
A transverse arteriotomy was then performed the left common femoral artery. Fogarty was passed and again a relatively small amount of thrombus was retrieved from the distal vascular bed. Proximally the Fogarty was passed and a modest amount of thrombus was retrieved from the iliac artery. Arterial inflow appeared to be adequate. The common femoral artery arteriotomy was closed with 6-0 Prolene suture.
*
The left medial calf was then excised in the popliteal artery exposed. The muscle and the left leg at this point appeared to be viable and not significantly swollen. The popliteal artery had a very weak pulse at this level. Transverse arteriotomy was performed and Fogarty passed both proximally and distally. No significant clot was retrieved proximally and very scant amount of clot was retrieved distally. The Fogarty passed to the foot level. Several negative passes were performed. Very poor backbleeding was observed. The transverse arteriotomy was closed and flow established in the popliteal artery. Due to the weak inflow will return to the left common femoral artery. The femoral artery was noted to be diseased and there was concern that the closure was further impeding flow through the area. The vessel was re-controlled and a longitudinal arteriotomy performed through the prior transverse arteriotomy. Significant obstructive plaque was encountered and a femoral endarterectomy was performed. Patch angioplasty was then performed with a bovine patch. Once the patch was completed flow was established and at least at the femoral level the signal sounded good with low resistance. Flow at the pedal level on the left however was not observed to improve and we still could not get detectable Doppler signals although the color of the left foot was improving marginally.
*
Ancef sponges and thrombin-soaked Gelfoam were applied in the incisions and attention was turned to the left arm which was already prepped and draped. A transverse incision was made at the antecubital fossa. The brachial artery was exposed and a transverse arteriotomy performed. Brachial embolectomy was performed by passing the #2 Fogarty catheter both proximally and distally. The catheter appeared to pass into the radial ulnar area distribution without much resistance down to the wrist level were obstruction was met. A significant amount of embolus was retrieved and some backbleeding was observed. Proximally no significant clot was retrieved and good inflow was observed. The transverse arteriotomy at the brachial artery was closed with Prolene suture. Palpable pulse was noted at the wrist level in the radial artery but very poor perfusion in the hand and no detectable signal in the palmar arch. A longitudinal incision was then performed in the wrist over the distal radial artery. The artery was exposed for several centimeters and was noted to be soft with a pulse that was resistant. A transverse arteriotomy was performed after controlling the vessel with aneurysm clips. Good inflow was noted. Distally a #2 Fogarty was passed into the hand with retrieval of some additional thrombus. Some backbleeding was observed. Several negative passes were made with the Fogarty. The transverse arteriotomy in the radial artery was repaired and flow reestablished. Flow was palpable in snuffbox branch of the radial artery. I could still not detectable flow in the palmar arch. The hand was showing some evidence of improved perfusion. The incisions at the radial and brachial level were closed with PDS and staples.
*
Attention was returned to the lower extremities. Sponges and thrombin-soaked Gelfoam removed. 10 flat Jackson-Pratt drains were placed in both groin incisions and the left calf incision. All of these drains were brought out through separate stab incisions. The groin incisions were closed with 3-0 PDS and 4 Monocryl. The Incision was closed with 3-0 PDS and staples. The right medial calf incision and fasciotomies were left a been and dressed with Xeroform gauze and bulky Curlex. Patient remained stable during the surgery.
are these correct?
34201 50
34203 50 51
27602 51
34101 51 lt
34111 51 lt