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EVAR Help

Please help with this EVAR, I cannot figure out when to bill for the extensions. Thank you

PROCEDURE:
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Lowest renal artery was LEFT
Ipsilateral long sheath French size was**16
Contralateral long sheath French size was**12
Endo-leaks found at completion aortography included: none
Aorto-iliac lesions specifically dilated included*left CIA origin
Kissing technique for dilating the bifurcation*was utilized.
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Main body component:Gore 26 x 12 x 18
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Contralateral limb component:**16 x 12 x12
After full preoperative evaluation and informed consent the patient was brought to the hybrid operating room and placed on the radiolucent table, with all surfaces carefully padded and protected. Monitoring devices were fully established, Foley catheter was placed, and an adequate level of endotracheal general anesthesia was achieved. Both incision sites were infiltrated with quarter percent Marcaine solution pre-emptive anesthetic technique. Previously marked by myself with ultrasound, the bilateral groins were opened through small transverse oblique incisions. The common superficial and deep femoral arteries were prepared for control with Silastic loops of Potts configuration. The patient was systemically heparinized. Anticoagulation status was monitored by the anesthesiologist and was therapeutic. Heparin supplements were given at intervals as needed.
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Entry into both common femoral arteries was obtained via single anterior wall puncture of each artery, and under fluoroscopy 6 French sheaths were positioned over the wires. On the IPSILATERAL *main body side over an 035 stiff angled glide wire a pigtail catheter was advanced to the level of the renal arteries. Aortography was carried out in anteroposterior projection. Distance between the lowest renal artery and the IPSILATERAL hypogastric artery was done. The main body device length was selected. Previous CT calculations in 3-D imaging had been done to calculate device diameters.
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The IPSILATERAL 035 angled Glidewire was exchanged via the pigtail catheter for a Lunderquist long stiff 035 wire and this was positioned under fluoro at the distal aortic arch. The external tip of this wire was marked and monitored on the draped table to prevent displacment. The pigtail was removed and transferred to the contralateral side over an 035 wire. This contralateral wire was then exchanged for a Lunderquist stiff 035 wire positioned at the distal aortic arch using these same precautions.
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The IPSILATERAL 6 French sheath and contralateral 6 French sheath were replaced under fluoro with the larger diameter long sheaths. These larger sheaths were positioned so that the hubs were within a few centimeters of the arteriotomies.
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Over the IPSILATERAL Lunderquist wire the main body device was carefully passed under fluoro so that its leading edge lay just at the origin of the lowest renal artery.
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Puff aortography was carried out via the contralateral pigtail catheter, confirming excellent position of the main body endograft. This device was then deployed down to the level of the IPSILATERAL gate, which opened uneventfully. Puff aortography was repeated confirming satisfactory deployment and assessing the need for re-capture of the device leading edge and readjustment. After satisfactory position was confirmed at the proximal landing zone, the contralateral pigtail catheter was pulled down to the level of the gate and maneuvers were carried out to enter the gate with an 035 angled Glidewire. The pigtail was advanced over this wire into the main body and allowed to reform into a curve. The curve was twirled under fluoro, confirming that the contralateral wire was positioned within the graft lumen. Leaving the pigtail in place, retrograde injection into the contralateral sheath was done. The pigtail was used to measure appropriate length for the contralateral endograft. With suitable overlap of the contralateral limb device obtained and distal endograft tip positioning proximal to the contralateral hypogastric artery origin, the contralateral endograft was deployed. Contralateral sheath injection confirmed excellent endograft limb placement.
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The main-body iliac limb was deployed. Compliant balloon was then passed first up the smaller diameter sheath, then up the larger diameter sheath. In each case the proximal landing zone was *carefully dilated, and both entire *iliac limbs were carefully dilated from the flow-divider distally.
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Pigtail *catheter was passed over a wire under fluoroscopy to the level of the renal arteries. Completion aortogram and runoff was carried out to evaluate for any endoleak and for appropriate position of the grafts.
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Once satisfactory deployment was confirmed, the sheaths were pulled over wires with control of the arteriotomy bleeding by snugging the femoral Potts ties. Once hemodynamic stability was confirmed, the wires were pulled and control of the femoral arteries was continued with Potts ties and atraumatic vascular clamps as needed. Arteriotomies were copiously flushed with heparin saline and arteriotomy repairs were done with fine Prolene suture. Prior to placing the final sutures the systems were flushed and de-aired, the final sutures *were taken and tied and flow was opened retrograde then antegrade.
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Both groins were *copiously irrigated with antibiotic and saline. The incisions were *reapproximated with layers of running Vicryl absorbable suture. Final careful check for hemostasis was satisfactory. Marcaine was reinstilled prior to closing the skin with running absorbable subcuticular skin stitches. Sterile dressings were placed. Distal pulses were evaluated and satisfactory. The patient was then awakened, transferred to the post-procedure area in stable condition having tolerated the procedure well

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