Hello – We would love someone to review our codes and provide feedback. Also, specifically, it’s our understanding that we code for both access sites, hence the use of 36140-XS-RT. Yes/No – Circumstantial? We are specifically being asked why we want to use this code.

These are the codes we want to use for this inpatient Medicare pt.
35371-RT
37221-RT
36140-XS-RT
75625

Many thanks. Kristi

Pre-op Diagnosis:
1. Atherosclerotic PVD with intermittent claudication RLE [I70.219]
2. CKD
3. HTN

Post-op Diagnosis: same

Procedure(s):
1. Right common femoral endarterectomy with bovine pericardial patch
angioplasty
2. Aortogram via L CFA approach
3. Selective catheterization of R EIA
4. R EIA PTA, stent placement, 8 x 60mm

Anesthesia: General

Estimated Blood Loss: 200 mL

CONTRAST: 50 cc

Drain: none

Total IV Fluids: see anesthesia log

Specimens:
ID Type Source Tests Collected by Time Destination
A : RIGHT FEMORAL PLAQUE Tissue Plaque SURGICAL PATHOLOGY

Implants:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No.
Used
PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X W.8 CM PERIPHERAL
STERILE – SN/A Patch PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X
W.8 CM PERIPHERAL STERILE N/A SYNOVIS MICRO COMPANIES ALLIANCE INC – A
BAXTER HEALTHCARE CORP CO SP18B02-1270178 Right 1
mynx N/A CARDINAL HEALTH INC F1805704 Left 1

Complications: none

Findings: R EIA occlusion with bulky calcified plaque extending into R
CFA. S/p endarterectomy. Unable to cross EIA lesion from retrograde
approach therefore L CFA access was obtained and lesion was crossed from
an antegrade approach. Self-expanding 8 x 60mm stent was placed was good
result. Palpable pedal pulses upon completion.

Disposition: awakened from anesthesia, extubated and taken to the recovery
room in a stable condition, having suffered no apparent untoward event.

Condition: doing well without problems

Technique:
After informed consent was obtained the patient was taken to the operating
room. Placed in the supine position. General endotracheal anesthesia was
administered. The abdomen and bilateral groins were prepped and draped
usual sterile fashion.

We began by making an incision in the inguinal
right area right groin midline between a cyst in the pubic tubercle in
vertical fashion. We dissected through the skin subcutaneous tissue
Scarpa’s fascia until we encountered the femoral sheath. Any veins that
were seen were tied off and suture ligated. Then got into the femoral
sheath identified our inguinal ligament and then our right common femoral
artery. It was noted to be calcified with some posterior plaque and some
inflammation noted. We dissected systemic fashion inferiorly identifying a
few branches and putting small Vesseloops around. We then identified the
SFA and profunda. Placed vessel loops around them. We then continued our
dissection more proximally we had to divide part of the inguinal ligament
to get more proximal control.

At this point, we began our endarterectomy
we heparinized the patient and obtained ACTs every 30 min to remain
therapeutic. Once the patient was therapeutic we got control with vessel
loops and then performed an arteriotomy with an 11 blade and extended it
with Potts scissors. The common femoral artery had noted hemorrhagic
calcified plaque. We then perform an endarterectomy between the median
intima with a Freer elevator and piecemeal off the plaque in the common
femoral artery. We then made our endpoint at the distal common femoral
artery. There was noted to be calcified posterior plaque on the proximal
aspect of our endarterectomy site with a chronic occlusion.

We attempted
to access through the open endarterectomy vessel the right external iliac
artery with a Glidewire 035 as well as a 5 French sheath. When we
advanced the wire and there was mild resistance proximally we advance into
what we thought was the abdominal aorta we then performed an angiogram
which demonstrated a dissection plane at this point we then stopped access
from this area. We removed the sheath and the wire and then gain access on
the opposite groin. At this point we then gain access to the left groin
under palpation using Seldinger technique.

We accessed the left common
femoral artery and then we upgraded to a 5 French sheath. We then
advanced a Glidewire and a VCF catheter and performed a angiogram with
minimal contrast. This demonstrated extensive infrarenal calcification in
bilateral patent common iliac arteries. The left hypogastric appeared to
be occluded. The left external iliac had multilevel disease but nothing
hemodynamically significant. The right common iliac artery appeared to be
patent the external had a flush occlusion about 1 cm after the takeoff.
The left hypogastric artery appeared to be patent with an ostial lesion.
There was extensive pelvic collaterals and reconstitution at the femoral
head of the common femoral artery. At this point we then upgraded to a 6
French up-Andover sheath and advanced it over the bifurcation into the
right common iliac artery. We then used a support Seeker catheter within
and a stiff 035 glidewire and was able to go through the chronic occlusion
of the left external iliac artery into our endarterectomy site in the
right common femoral artery. We then switched snared the Glidewire
through the right common femoral artery endarterectomy site. At this point
we then placed a 6 French sheath through the Glidewire in the right groin
and then we used a 8 x 60 mustang balloon used to measure the length of
our occlusion. At this point we then decided to use a 8 x 60 self
expanding stent. We deployed the stent in standard fashion at the takeoff
of the hypogastric artery with the endpoint proximal to the femoral head.
We then post dilated with a 8 x 60 mustang balloon. Postop angiogram
demonstrated good apposition of the stent with no hemodynamic significant
stenosis noted. We then at that point, performed a patch angioplasty with
a pericardial patch with 6 0 Prolene in standard fashion. Before
completing the patch angioplasty we forward flushed and backflushed the
common femoral artery. Before completing the full angioplasty, we left
the wire in place and then performed a angiogram which demonstrated
patency of the right common iliac artery as well as external iliac artery
and common femoral artery with no hemodynamic significant stenosis. The
right groin shot demonstrated patency of the profundus as well as the SFA.

At that point we then finished our patch angioplasty and endarterectomy
site. Everything was noted to be hemostatic and mildly oozy. We reversed
the patient with protamine. We dried out any bleeding points with Bovie
electrocautery and clips. We then closed the right groin in layers of
Vicryl multiple. We closed that the subdermal with 3 0 Vicryl pop offs
and the skin with 4 O Monocryl subcuticular stitches. Sterile dressing was
then applied.

On the left groin we downsized to a 6 French sheath over the
wire under fluoroscopic guidance. We then used a 6 French Mynx closure
device and closed the left common femoral artery at the access site. In
standard fashion. Sterile dressing was then applied. At completion of the
procedure the patient had a palpable right pedal pulses. Patient tolerated
the procedure well was extubated transferred to the PACU in stable
condition.