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Endovascular stent repair of AAA

I am super stuck :confused: I keep leaning towards 34708 but something tells me I’m missing something… Any one want to take a shot and try to help please!

PREOPERATIVE DIAGNOSIS:
Abdominal aortic aneurysm.

POSTOPERATIVE DIAGNOSIS:
Abdominal aortic aneurysm.

PROCEDURE:
Endovascular stent repair of abdominal aortic aneurysm.

OPERATIVE PROCEDURE:
The patient was brought to the operating room, placed on the operating table.
After adequate general anesthesia, the patient’s groin area was shaved and both
legs were prepped from the toes all the way up to the umbilicus. The patient
was then draped in the usual sterile manner. Bilateral curvilinear groin
incisions were then made and dissection was carried down to the femoral
vessels. On the right side, the common femoral artery was identified and it
was dissected free circumferentially and encircled with a vessel loop. The
patient had enough common femoral artery here that a second vessel loop could
be placed distally such that a segment measuring about 2.5 cm exposed. On the
right side, the common femoral, superficial femoral, profunda vessels were all
dissected free circumferentially and encircled with vessel loops. On each side
using a Cook needle, guidewire was inserted into the femoral vessels followed
by a 5-French sheath. This was all done under fluoroscopic guidance. Once
this was done, we went ahead and placed our Glidewire up further proximally
through the iliacs, through the aneurysm up into the proximal descending
abdominal aorta. Again, all under fluoroscopic guidance. On the left side, a
Kumpe sheath was inserted into the artery. The Glidewire was replaced with a
stiff Bentson wire and over this, we went ahead and passed our main body
device, which was an Endurant II 25 x 14 x 103. The device was positioned into
place, but not deployed. On the right side, we went ahead and placed a pigtail

catheter and an on-table angiogram was then performed. The left renal artery
was identified. The patient had a nephrectomy on the right side. The graft
was then gradually deployed angling the gate more anterolaterally to the left.
The main body was deployed until the gate opened. At this point, the pigtail
catheter on the right side was then removed over a guidewire and replaced with
a Kumpe sheath. Attempt was made to cannulate the gate without success, an
angling sheath had to be then used to cannulate the gate successfully. The
guidewire was then passed up through the gate. Angling sheath was then
removed, and a sheath was then placed over the guidewire as well as a pigtail
catheter and an on-table angiogram was then performed. The distance from our
bifurcation to the iliac takeoff was measured, it appeared that a 16 x 16 x 124
length catheter would be appropriate here and the pigtail catheter and sheath
was then removed over wire and the right limb extension device was then
inserted and then, deployed successfully down to the level of the internal
iliac takeoff on the right. Similarly on the right side, a similar procedure
was performed. It should be noted that our suprarenal anchoring device had
already been deployed and the remaining portion of our graft on the left side
was deployed. The device was then removed and replaced with a sheath. Once
again, a pigtail catheter was also inserted and once again an on-table
angiogram was performed on the left side, distance to our internal iliac
takeoff was measured and it appeared that a 16 x 16 x 93 limb would be the
appropriate size. The pigtail catheter removed and our device was then
threaded over the wire and through our sheath up to our main body graft. The
device was then deployed successfully down to the internal iliac takeoff. At
this point, 2 Reliant balloons were inserted up each limb and inflated
sequentially down the entire length of the aortic graft and the limbs. Once
this was done, a completion aortogram was then performed. This showed good
seal without any endoleaks or no kinks within the graft. At this point, the
sheaths and wires were all removed and the arteriotomies in our femoral vessels
were closed using interrupted 6-0 Prolene sutures. The wounds were irrigated
and aspirated. The wounds were closed in layers with deep layers of 2-0
Vicryl. The skin was closed using 4-0 Monocryl using a subcuticular stitch and
dressed with Steri-Strips, 4×4 gauze, and tape. The patient tolerated the
procedure well without any complications. Anesthesia was reversed. The
patient returned to the recovery room in satisfactory condition. In the
recovery room, the patient was noted to have palpable pedal pulses as he did
preoperatively. Total contrast used was 70 cc and our fluoro time was 34
minutes and 51 seconds.

Medical Billing and Coding Forum

Endovascular repair, still confused!

ANY HELP, ADVICE, DIRECTION WILL BE GREATLY APPRECIATED :) I GOT 34705 & 34812/50. IT DOESN’T SEEM RIGHT… THANKS!! CAROL

PRE-OPERATIVE Abdominal aortic aneurysm.

DIAGNOSIS: POST-OPERATIVE Same.

DIAGNOSIS: ESTIMATED BLOOD Less than 20 cc. LOSS

ANESTHESIA: General anesthesia.

DESCRIPTION OF PROCEDURE: Right and left common femoral arteries were accessed percutaneously and a Perclose sutures were placed bilaterally using the pre-close technique. Catheter and guidewire
techniques: were used to manipulate a Lunderquist wire from the left common femoral
arteriotomy to the mid thoracic aorta. Catheter and guidewire techniques were used to
manipulate a pigtail catheter to the upper abdominal aorta. Over the left-sided
Lunderquist wire, the main body Endurant stent graft measuring 16 x 13 x 124 mm mm
was advanced to the upper abdominal aorta. An aortogram was performed in the
craniocaudal projection to delineate the takeoff of the renal arteries. The stent graft was
then deployed to the level of the gate such that the proximal fabric lies immediately
distal to the takeoff of the lower most left renal artery. The hooks were deployed in
usual fashion. Next, the right-sided pigtail catheter was straightened and used to select
the gate. The pigtail catheter was advanced into the main body stent graft and spine to
ensure its intraluminal position. A Lunderquist wire was then advanced into the pigtail
catheter A right-sided iliac angiogram was performed to delineate the position of the
native aortic bifurcation and right hypogastric artery. The pigtail catheter was
exchanged over the Lunderquist wire for the delivery system for a right-sided iliac
extender measuring 25 x 13 x 166 mm. This was advanced into the gate and deployed
in the usual fashion such that the distal fabric is immediately proximal to the right
hypogastric artery takeoff. The delivery system was then removed and replaced with a
12 French sheath Next, the main body stent graft was deployed in its entirety. The
delivery system was then removed and replaced with a 14 French sheath. Next, the stent
graft and both right and left limbs were dilated using Reliant balloons and kissing
balloon technique. Next, both right and left arteriotomies were closed using the Perclose
sutures and satisfactory hemostasis was obtained.

ANGIOGRAPHIC FINDINGS: Following placement of a modular bifurcated stent graft, there is satisfactory flow through the stent graft and both right and left limbs. There is maintenance of patency of
both right and left renal arteries and right and left hypogastric arteries. There is a slight
proximal type I endoleak present which was refractory to multiple balloon dilatations at
the proximal landing zone.

COMPLICATIONS: None.

CONCLUSION: Successful placement of a modular bifurcated stent graft for treatment of an infrarenal
abdominal aortic aneurysm. At the conclusion of the procedure, the stent graft is in
satisfactory position with excellent flow. A slow filling proximal type I endoleak
persists despite multiple balloon dilatations at the proximal landing zone. The patient
will be followed with CT scanning in approximately one week. Should the patient have
a persisting type I endoleak, the plan is to the percutaneously additional stents at the
level of the proximal landing zone.

Medical Billing and Coding Forum

Endovascular procedure, so confused!

Help! this is my first time for one of these procedures…. I can’t tell if the doctor has confusing dictation, or it’s just me. I got 33880 (62?) 75956/26, 37252, 37253 & 36200. What do the experts think? thanks for any and all input!

DIAGNOSIS: POST-OPERATIVE Type B aortic dissection.

DIAGNOSIS:

SURGEONS: K….
ESTIMATED BLOOD 200cc

LOSS:

DESCRIPTION: Informed consent was obtained . The patient was brought to the operative suite where
Dr. Koumjian performed right common femoral artery exposure. No common femoral
artery was punctured percutaneously and a 6 French sheath was placed. Catheter and
guidewire techniques were manipulated used to manipulate a Glidewire into the true
lumen of the thoracic aorta over which a pigtail catheter was advanced and positioned
within the ascending aorta.

A 10 French sheath was placed into the exposed right common femoral artery. Catheter
and guidewire techniques were used to manipulate a Glidewire into the false lumen of
the thoracic aorta. Over this wire, the intravascular ultrasound catheter was advanced in
interrogation of the false lumen was performed. This confirms that the Glidewire does
not enter and exit through fenestrations. Also confirmed with the luminal diameter of
the false and true lumina and position of the takeoff of the left subclavian artery. This
catheter was then exchanged for a Berenstein catheter which was used to select the left
subclavian artery. An angiogram was performed to document the position of the left
common carotid to left subclavian artery bypass. Next, a over exchange wire, a 7
French destination sheath was passed into the proximal left subclavian artery. Through
this sheath, 2 tandem 16 mm Amplatz or plugs were placed into the proximal left
subclavian artery successfully occluding both true and false lumen of this vessel.

Next, the destination sheath was exchanged over a guidewire for a Berenstein catheter
which was used to select the true lumen from the right common femoral artery. Over a
guidewire, intravascular ultrasound was passed through the true lumen and used to
interrogate the luminal diameter of the true lumen at the level of the aortic arch which
measured approximately 28 mm.

Next, a Lunderquist wire was advanced through the intravascular ultrasound catheter
which was then removed and exchanged for the delivery system of a Valiant endograft
measuring 28 x 28 x 150 mm. A thoracic aortogram was performed to delineate the
takeoff of the left common and innominate arteries which takeoff of a common bovine
trunk. The endograft was deployed such that the proximal fabric lies immediately distal
to the takeoff of the bovine trunk. This endograft was then deployed in its entirety.

The pigtail catheter was then straightened and replaced into the lumen of the recently
placed endograft and a distal thoracic aortogram was performed to take to delineate the
takeoff of the celiac artery. Next, over the right-sided Lunderquist wire the delivery
system for a Valiant endograft measuring 28 x 24 x 150 mm was advanced and
positioned into the distal portion of the previously placed endograft and deployed in the
usual fashion such that the distal fabric lies significantly proximal to the takeoff of the
celiac axis.

ANGIOGRAPHIC FINDINGS:
Next, the pigtail catheter was advanced through the endograft and positioned within the
ascending aorta for a final thoracic aortogram, the results of which demonstrates
satisfactory exclusion of a type B dissection false lumen. There is maintenance of
excellent flow through the bovine trunk. There is opacification of a widely patent left
common carotid artery to left subclavian artery bypass graft there is filling of the distal
left subclavian artery. There is satisfactory occlusion of the embolized proximal left
subclavian artery. There is no evidence of endoleak.

The left common femoral artery sheath was removed and the left common femoral
arteriotomy was closed with a starclose device.

Dr. Koumjian close the right common femoral artery or in the groin. The patient was
taken to the recovery room in stable condition.

CONCLUSION: Successful restoration of luminal diameter of the true lumen which was compromised
secondary to a type B aortic dissection and widening false lumen via placement of
modular thoracic endografts as detailed above.

Billing codes: 34812-62, 36200, 36215, 33880-62, 75956-26, 37252, 37242.

Medical Billing and Coding Forum

Percutaneous endovascular repair of AAA with stent in the graft HELP PLEASE

I need help with this procedure please. I have never done this and could use all of the help I can get. This is my physicians report and he is the interventional cardiologist. Please let me know where I can find information to help me with this. Thank you in advance.

Interventional Cardiologist: Dr. A

Co-Surgeon: Dr. B

TITLE: Percutaneous endovascular repair of abdominal aortic aneurysm with
stent in the graft.

INDICATION FOR THE PROCEDURE: This is a gentleman with
diagnosed abdominal aortic aneurysm, without rupture. The aneurysm was
followed and had a CTA performed earlier in the year, with the size of the
aneurysm at 62 mm. The patient has known coronary artery disease with
status post bypass surgery and recent percutaneous coronary intervention
with drug-eluting stent of his left main and circumflex. He also has
known bilateral peripheral vascular disease with bilateral fem-pop
bypasses. Pros and cons of endovascular procedure was in detail discussed
with the patient. Consent was obtained, procedure was commenced.

ANESTHESIA: Anesthesia was provided by anesthesia Department. The
patient was intubated and sedated by protocol.

DESCRIPTION OF PROCEDURE: Vascular access was obtained first to the right
common femoral artery with micropuncture kit. The access was obtained
with a 7 French sheath to the right common femoral artery. The 6-French
IM catheter was placed through the sheath and angiogram of the left iliac
and femoral artery was obtained. Then, under the angiogram control, an
access of the left common femoral artery, again with a micropuncture kit
was performed. The arteriotomy site was preclosed with two PerClose
closure devices, then a stiff wire was placed and access was predilated
with 10 and 14 dilator and then 17-French sheath into the ipsilateral left
femoral artery was placed. Angiogram was performed to remeasure vessel
length, reevaluate the anatomy and suitability of a percutaneous
intervention and the ipsilateral left and contralateral right access
vessels were not predilated. The initial stiff Bentson wire was exchanged
on the ipsilateral side for super stiff 0.035 inch wire. Then, we loaded
the 25-110-20-30 AFX2 bifurcated device until the stiff wire from the left
access and advanced the contralateral wire up through the 17-French AFX
introducer sheath using wire guide. Contralateral wire was snared with a Tulip
snare and pulled out from the contra side. AFX2 bifurcated device was then
transferred into the AFX introducer sheath and advanced under fluoroscopy
control until the distal limbs were above the aortic bifurcation releasing the
limbs of the graft. Then, entire system was pulled down onto the aortic
bifurcation and the main body of the graft was deployed by pulling on the
control cord handle. We deployed the
contralateral limb by pulling the yellow limb, then advancing a pigtail
catheter over the contra wire until the tip was in contact with the wire
lock. Held the pigtail catheter in place and pulled on the contrawire to
relieve it from the wire lock.

Deployed the ipsilateral limb by pin the inner core and retracting the AFX
introducer sheath. Then we advanced and deployed the 28-95 infrarenal and
the graft and performed angiogram to visualize the renal arteries. The
endograft was deployed exactly below the renal arteries without any
obstruction.

At 20-25/55, iliac extension was placed on the left side and deployed. We
performed the final angiogram with a pigtail catheter positioned to the
abdominal aorta which showed excellent procedural result with excellent
stent graft position, no evidence of endoleak and full coverage of the
aneurysm. Then the catheters were removed. The 7 French sheath from the
left femoral artery was pooled and proglide sutures were tightened. This
allowed excellent hemostasis on the left. The heparin used during the
procedure was reversed by protamine. The right femoral sheath was pulled
and access site controlled with a manual pressure. Procedure was
completed.

CONCLUSION:

1. Large abdominal aortic aneurysm 6.2 cm in diameter, nonruptured.
2. Successful percutaneous endovascular repair of the abdominal aortic
aneurysm with Endologix bifurcating AFX2 devise with infrarenal graft
extension and left iliac covered stent extension.
3. The patient to
continue his current medications and will be followed by standard
protocol, expect discharge on 06/28/2017.

Medical Billing and Coding Forum

Billing 75246 with endovascular revascularization 37225 and 37228

It’s my first time working with Vascular procedures and our Provider coded the fem/pop revascularization along with tib/per and also coded the aortic angiography. His report does indicate that he passed through the aortic bifurcation so I’m not sure if that is something that would apply to this? Any advice would help.

Medical Billing and Coding Forum