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Tag Archives: EVAR

Endoleak—Endovascular repair of AAA s/p EVAR endoleak

Posted on by
Can someone help with this. It’s out of my wheelhouse. Thanks!

Operation

1. Bilateral open femoral artery exposure.
2. Endovascular aneurysm repair with placement of aortic-uni-iliac endogradt, non rupture.
3. Right common iliac artery embolization
4. Left to right femoral to femoral bypass

Technique
1. Bilateral open femoral artery exposure
2.Placement of catheter in abdominal aorta with aortogram.
3.Introduction of the main body device Medtronic Endurant II AUI 28 mm x 14mm x 102 mm from the left common femoral artery
4. Left limb 16 mm x 93 mm
5. Left limb extension 20 mm x 156 mm
6. Left to right femoral to femoral bypass with 8 mm Dacron graft

Procedure:
Bilateral oblique groin incises were created with a scalpel two finer breaths below the inguinal ligament. Electrocautery was utilized to dissect through the subcutaneous tissues to expose the inguinal ligament. The femoral sheath was identified and divided longitudinally to expose the common femoral artery. The proximal and distal common femoral arteries were then circumferentially encircled with silastic vessel loops.The left common fem artery was accessed with an 18g needle, Benton wire, and 9 french sheath. The bentson wire and KMP catheter was advanced into the suprarenal aorta to perform an aortogram.

The 14 french main body Medtronic Endurant II AUI device was placed on the left side. On the contralateral side, a pigtail catheter was inserted to the level of the renal arteries and an aortogram was performed. The main body device was then positioned just below the right renal artery and the endo graft was fully deployed. An aortogram was performed to confirm adequate position of the graft and patent right renal artery.

The left iliac limb was measured with the marked pigtail catheter and the location of the hypoastric artery was confirmed with a retrograde sheath arteriogram.The left iliac limb grafts were deployed just proximal to the left hypogastric artery wiht a 3xm uverlapof the previous left iliac limb. All overlap zones were confirmed wiht a Reliant balloon. Next, the previous placed right iliac limb was embolized with a 22 mm Amplatzer Ii plug thru a 12 French long sheath.

A complete aortogram was performed which confirmed excellent endograft position and patent right renal artery and hypogastric arteries bilaterally. No endoleak was detected. Bilateral common femoral arteries were then controlled proximally and distally with vascular clamps. A tunnel was created over both inguinal ligaments, anterior to fascia along the subcutanouse space, superior to pubis using blunt dissection. An 8,=mm Dacron graft passed thru the tunnel ensuring no kinking or twisting. A longitudinal arteriotomy was made on the left common femoral artery. No endarterectomy was required. ..then closure

34703
34812
34709??
34813

??????

thanks for your help!!

Medical Billing and Coding Forum

EVAR Help

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

PROCEDURE:
*
.
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.
*
Main body component:Gore 26 x 12 x 18
*
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.
*
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.
*
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.
*
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.
*
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.
*
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.
*
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.
*
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.
*
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.
*
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

Medical Billing and Coding Forum

EVAR Coding Assistance

Posted on by
I am new to EVAR coding and need confirmation that I am coding this report appropriately. My provider uses the term "extension" in his report, but I don’t think that it is truly an extension that I can code for as it does not appear that it is placed distal to the common iliac artery. I came up with CPT 34705-62 for this report. Please confirm.

Pre-Operative Diagnosis: Abdominal Aortic Aneurysm
*
Post-Operative Diagnosis: Successful Endovascular AAA Stent Graft Placement
*
Abdominal Aortogram, Bilateral Iliac Angiogram and AAA Stent Graft Placement
*
INDICATION FOR PROCEDURE:
Infrarenal abdominal aortic aneurysm more than 5 cm in diameter
*
Nature of procedure, including benefits, alternative and risks, e.g. bleeding, CVA, MI, renal failure, infection, emergency CABG and even death explained.
*
CO-SURGEON: Dr. XXXXX and Dr. XXXXX
*
CONTRAST:
* Intraprocedure medication information is unavailable because the case start and end events have not been set *
*
NAME OF PROCEDURE:
1. Insertion of bilateral arterial sheath and catheter placement via both femoral arteries.
2. Abdominal aortogram with bilateral selective iliac angiogram to facilitate stent graft placement.
3. Placement of a Cook Zenith AAA stent graft main body by flex flex body 30×111 mm device via the left groin.
4. Placement of a contralateral limb via the right groin using a Cook Zenith spiral limb extension 20×74 mm iliac limb.
5. Placement of a left iliac limb extension using a Cook Zenith spiral limb extension 11 X 74 mm iliac device.
6. Balloon angioplasty of all stent graft anastomosis site using a Coda balloon.
*
*
DESCRIPTION OF PROCEDURE:
After an informed consent, the patient was brought into the cath lab and prepped and draped in the usual fashion. General anesthesia was administered by anesthesiologist and the anesthesia record will be reported separately.
Bilateral femoral artery cutdown was performed by Dr. XXXXX. His cutdown report will also be dictated separately.
After bilateral arterial cutdown, bilateral 7-French sheath was placed under Seldinger technique under open condition without complication. Bilateral arterial catheterization was performed using a soft Glidewire and then exchanged out for 2 stiff Lunderquist guide wires. A 6-French Royal Flush pigtail catheter was advanced from the right groin into the abdominal aorta above the renal arteries. Suprarenal abdominal aortogram was performed to evaluate position of the renal artery so as to use it as a landmark for stent graft placement. The left renal artery appeared to be the lower vessel and was used as a landmark. Subsequently, a Cook Zenith main body 30×111 mm Tri-Flex flex body device was advanced from the left groin into the abdominal aorta at the junction of the left renal artery. Prior to that slow subsequent dilatation was done with 16, 18 and 20 mm dilator Slow deployment was performed where we were able to precisely place the stent graft below the left renal artery as well as to allow the contralateral limb to open up toward the anterior projection. Subsequently, we were able to exchange out for a soft wire and a Headhunter catheter to access the contralateral limb from the right side without difficulty. Confirming position of the wire into the main body from the contralateral limb using a pigtail catheter, we were able to measure the size and the length of the device that we need. After insuring that we were truly in the true lumen of the contralateral limb, we were able to deliver a 20×74 mm Zenith spiral limb extension contralateral limb device with at least 1 to 1-1/2 graft overlap distally without occlusion of the internal iliac artery. The right limb deployed slowly without complication.
After the rest of the main body limb was fully deployed on the left side, the pigtail catheter was exchanged out in the left side. Left iliac angiogram was subsequently performed where we were able to precisely locate and measure the size of the device we need for the right limb extension. After measuring the length, we were able to determine that a 11×74 mm Zeta spiral limb extension iliac limb distention was needed for the left-sided. Subsequently the 11×74 mm left iliac limb extension was advanced and deployed with 1 to 1-1/2 stent overlap into the main body and with good opposition of the distal side without occlusion of the internal iliac artery. After all stent grafts were deployed, at that point, we used a Coda balloon and inflate all attachment sites using the Coda balloon at low pressures. The ostium of bilateral iliac artery needed to be further dilated with 10×40 mm peripheral balloon Subsequently, angiography was performed which demonstrated excellent main body main AAA stent graft position without occlusion of the renal artery. There was no endoleak seen by the lumbar vessel, which is not significant. At that point, both cutdown sites were repaired by Dr. XXXX and Dr. XXXXX without complication. The patient was subsequently gradually recovered from anesthesia and was transferred to recovery room in stable condition.
*
FINAL IMPRESSION:
Successful placement of a Zenith AAA endograft with main body through the left side with bilateral iliac extension was performed without complication.
*
FINAL DIAGNOSES:
Successful abdominal aortic aneurysm sealed with endovascular graft with bilateral iliac limb extension
RECOMMENDATION:
Recommend routine post-aortic stent graft monitoring. Will followup CT with ultrasound in 3 months and yearly as indicated to rule out endoleak.

Medical Billing and Coding Forum

Vascular access for 2018 new evar code 34710

Posted on by
The CPT code 34710 for delayed placement of distal or proximal extension prosthesis does not include arterial access and closure and CPT states for open artery exposure, use 34714-34716, 34812, 34820, 34833, or 34834 in addition to 34701-34708 or 34710, when applicable. For percutaneous arterial closure, use 34713 in addition to 34701-34708 or 34710, when applicable. The problem I am encountering is that all the codes stated do not list 34710 as a primary code and it is resulting in denial of the open femoral access.
Has anyone else encountered this problem? How are you solving it?

Thanks, for any help and/ or input.

Medical Billing and Coding Forum

Need opinion on new EVAR code selection for 2018 OP Note

Posted on by
Hello,

I’m in need of a second opinion. I have coded this for the Operative Note that follows. Am I correct with the new EVAR coding(2018) or am I missing something? Thanks!

34703
34812-50

Diagnosis Code is I71.4

PROCEDURES PERFORMED:
1. Bilateral common femoral artery exploration.
2. Endovascular repair of AAA aneurysm with Gore graft, right main body 31 mm x 14.5 mm x 13 cm.
3. Left contralateral bell bottom 18 mm x 11.5 cm.
4. Right ipsilateral extension bell bottom 20 mm x 11.5 cm.

ANESTHESIA: General endotracheal anesthesia.

INTRAVENOUS FLUIDS: 1500 mL.

ESTIMATED BLOOD LOSS: 100 mL.

URINE OUTPUT: 100 mL.

SPECIMEN OBTAINED: None.

DISPOSITION: PACU.

FINDINGS: The infrarenal abdominal aortic aneurysm was sealed with the stent graft and there was no endoleak noted at the end of the case.

INDICATIONS FOR PROCEDURE: The patient is an 83-year-old male who was noted to have an enlarging infrarenal saccular aneurysm, which was initially noted on a CT scan. He was noted in September 2017 to have aneurysm measurements 4.15 x 4.39 cm and in December 2017, he had a CT abdomen and pelvis done without contrast and at that time 0.2 cm.

Given this enlargement in the aneurysm, the patient was then booked and consented for the above-mentioned procedure. The patient was explained the risks and benefits of procedure, bleeding, infection, wound breakdown, possibility of conversion to open, possibility of bowel ischemia, paralysis, long ICU stay, kidney failure, and the patient gave informed consent.

DETAILS OF PROCEDURE: On the date of the surgery, the patient was brought to the operating room and laid down supine on the operating table. General anesthesia was provided by the anesthesia department. A Foley catheter was placed by the anesthesia department as well. The patient was given Ancef 2 g by the anesthesia department. A Foley catheter was placed. The patient’s bilateral groins and abdomen were prepped and draped in sterile fashion.

A time-out was obtained by the attending physician. We started by making transfer incisions on the bilateral groins to expose the common femoral artery. The common femoral artery was then dissected circumferentially. Proximal umbilical tape was placed distally. A vessel loop was placed. The patient was then given 5000 units of IV by the anesthesia department. Access was then obtained in the bilateral groins using Potts needle. A 0.035 wire was then placed through the needle and using Seldinger technique, a short 6-French sheath were then placed bilaterally. We started by placing 0.035 wire through the right-sided sheath and a pigtail was placed over it. We then obtained aortogram and bilateral pelvicogram to look at the renals and the length of the neck and measure the length from the renals to the bifurcation as well as to the right common iliac bifurcation. After this was done, a stiff Lunderquist wire was then placed through the pigtail and placed in the patient’s thoracic aorta. The tip of the catheter was then removed. The short 6-French sheath was then removed and then on the right side 18-French sheath was then placed into the patient’s infrarenal aorta.

A 0.035 wire and a Kumpe catheter was then placed into the patient’s thoracic aorta coming from the left side. The 0.035 Glidewire was then switched for a 0.035 Lunderquist wire. The tip of the Lunderquist wire was then placed in the patient’s thoracic aorta. The short sheath was then removed and then switched for a 12-French long sheath, which was also placed then to the level of the infrarenal aorta. Next, the pigtail catheter was then placed through the left-sided sheath into the patient’s abdominal aorta. The main body was then placed via the right side through the sheath to the level of the infrarenal aorta. Fluoroscopy machine was then angled craniocaudal for para lacks. Aortogram was then performed and the renal arteries were marked on the screen. The main body of the graft was then opened up partially to deploy the proximal part of the graft and open the gate. The open was then gated about 10 o’clock position. A 0.035 Glide Advantage was then placed to the pigtail catheter and the pigtail was pulled back over it. We then made several attempts, the gate with the help of a Kumpe catheter and 0.035 Glide Advantage wire coming via the left-sided sheath. We noted that we have to remove our graft gate more lateral so the graft was free constrained and rotated and repositioned again with the help of fluoroscopy. Once that was sent, we again used a 0.035 Glide Advantage and the Kumpe catheter coming from the left-sided sheath to cannulate the gate. At this time, we were able to do so. The pigtail catheter was then placed after removing the Kumpe catheter and we rotated the pigtail catheter inside the graft, making sure that we were within the graft, which we were. Next, keeping the pigtail in place, we then pulled back on the left sheath to where it was below the bifurcation of the left common iliac artery. A run was then performed to get the measurements for the length of the contralateral limb. We then obtained an 18 mm x 11.5 cm bell bottom contralateral stent graft and placed it over the left-sided Lunderquist wire and thereafter the 18 x 11.5 cm stent graft was then deployed from under fluoroscopy. Once that was done, we then pulled back the sheath on the right side and completed the deployment of the main body on the right side. We then obtained the 12 mm x 11.5 cm bell bottom and it was placed on the right side after we did a run to mark the right common iliac artery bifurcation. Once that was done, we then obtained a Q50 Gore balloon and the balloon was then inflated and then the aortic graft was then sealed at the proximal end at the gate and at the distal ends as well as the distal end in the common iliac artery. Once that was done, the pigtail catheter was then placed via the left-sided limb and a completion aortogram was then obtained. No EndoClips was noted. The deployment of the graft was proper. The graft was distal to the left renal, which was the lowest renal and distally graft was at the level of the bifurcation bilaterally and the common iliac arteries.

After that was done, proximal and distal control was obtained after pulling the sheath and the common femoral arteries. Bilateral arteriotomy was then repaired using interrupted CV-6 suture. The sutures were then tied down after doing forward and backward flushing. The wounds were then checked for hemostasis. The wounds were then closed in multiple layers using 2-0, 3-0, and 4-0 Monocryl sutures. Dermabond was then applied to the incision. The patient was then extubated and transferred in stable condition. The patient continued to have palpable pedal pulses. All the instruments and needle counts were correct at the end of the procedure.

Medical Billing and Coding Forum

EVAR performed in Rt aortofemoral graft

Posted on by
I am so lost on what to code for this report. I am thinking 37236? Please help!

Selective right aorto-femoral graft angiogram
Endovascular graft placement within the right aortofemoral CryoVein graft – Viabahn 13.0 mm x 10 cm self-expanding covered graft

Operators:
Dr. A
Dr. B

  1. Right aortofemoral graft access. Right aortofemoral graft access was obtained via surgical cutdown by Dr. B. Next an 11 French sheath was placed.

  1. Selective right aortofemoral graft angiogram. Next a glide catheter was advanced over the wire to the proximal right aortofemoral graft and baseline angiogram was performed. This revealed large pseudoaneurysm of the distal aspect of the graft.

  1. Endovascular graft placement within the right aortofemoral CryoVein graft. Next an Amplatz extra stiff wire was placed through the glide catheter and the glide catheter was removed. Next a Viabahn 13.0 mm x 10 cm self-expanding covered graft was advanced to the appropriate location and deployed. Next the Viabahn graft was postdilated with 12.0 mm charger balloon. Final angiogram revealed no residual pseudoaneurysm and no evidence of dissection, perforation or flow limitation. Next the catheter was removed and the 11 French sheath was removed and hemostasis obtained. Surgical cutdown was then closed.

Findings:

Large pseudoaneurysm of the distal aspect of the right aortofemoral CryoVein graft

Conclusions

Successful closure of pseudoaneurysm of right aortofemoral graft with Viabahn 13.0 x 10 cm self-expanding covered endoprosthesis

Medical Billing and Coding Forum