Thrombectomy

Can anyone pls confirm my codes for the below procedure,

37221

35371

37184

37185

PREOPERATIVE DIAGNOSIS: Acutely ischemic right lower extremity.

POSTOPERATIVE DIAGNOSIS: Acutely ischemic right lower extremity.

PROCEDURE:

1. Right groin exploration.

2. Extensive endarterectomy of the right common femoral artery with bovine

pericardial patch.

3. Thrombectomy in the right lower extremity.

4. Angiogram in the right lower extremity.

5. Selective catheterization of the right anterior tibial artery.

6. Over-the-wire embolectomy of the right anterior tibial artery.

7. Over-the-wire embolectomy of the right peroneal artery, completion

angiogram.

8. Angiogram of the distal aorta and right iliac artery.

9. Placement of 6-mm x 17-mm Express LD stent right proximal external iliac

artery, completion angiogram.

10.Percutaneous transluminal angioplasty of the right external iliac artery

using a 5-mm x 100-mm balloon, completion angiogram.

INDICATIONS FOR PROCEDURE: The patient is a 63-year-old man, who was admitted

to hospital last night with right leg pain. The patient has been a heavy

tobacco smoker for the past 45 years, smoking up to a pack of cigarettes a

day. Five days ago, he developed acute onset of right leg pain. He

attributed this to using inversion table and thought that this contributed to

his right leg pain. He subsequently developed rest pain, requiring his to

sleep in a chair and the following day developed cyanosis of the right 4th and

5th toes

CTA confirmed occlusion of the right common

and superficial femoral arteries with a high-grade stenosis in the right

external iliac artery. The patient was placed on heparin overnight and his

foot improved. However, he still had pain on his right first and fifth toes,

and still cyanosis of the right fourth and fifth toes.

DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient brought

to the operating room and placed in supine position. Adequate anesthesia was

obtained using LMA. The patient's right groin was prepped and draped in

normal sterile fashion. Time-out was performed confirming the patient,

operative procedure and location. Standard groin incision was made with

subcutaneous tissue was divided with electrocautery.

Dissection was carried

down to the right common femoral artery. The common deep and superficial

femoral arteries were encircled with vessel loops. The patient was given a

bolus of heparin 8000 units IV. Note, the common femoral artery was very hard

and had extensive plaque present. Therefore, it was decided to do a

longitudinal atherectomy and endarterectomy. An 11 blade scalpel was used to

enter the right proximal superficial femoral artery and this was extended up

to in the common femoral artery with Potts scissors. There was extensive

plaque throughout the common femoral artery, causing a stenosis of 80% to 90%.

In addition, there was thrombus at the distal common femoral artery as well.

A #4 embolectomy catheter was first passed distally and a large amount of

thrombus was removed, and then passed out. This was first passed down to

approximately 40 and then 50 and then 60 cm. A #3 embolectomy catheter was

then passed distally and a little bit of more thrombus was removed. There was

backbleeding after this. There was no thrombus in the deep femoral artery

with balloon embolectomy. Then passed the embolectomy catheter up to the

iliac artery. No thrombus was removed. However, the outflow was not very

brisk. A 6-French sheath was inserted in the right common femoral artery. An

angiogram was performed through hand-held injections, which showed excellent

flow down the superficial femoral artery and popliteal artery was widely

patent. However, the patient had severe tibial disease. There are no main

vessels filling the distal calf. We could see the origin of the anterior

tibial artery. Proximal anterior tibial artery was patent, but not the

distal. Therefore, I passed the 18 guidewire down with the aid of an angled

Glide catheter. We angled this down into the anterior tibial artery over the

wire. Embolectomy was performed with #3 embolectomy catheter and

approximately __________ segment of thrombus was removed. Then passed the

guidewire down to what appeared to be the peroneal artery, passed and

performed over the wire embolectomy catheter again. I did not remove any

thrombus from the peroneal artery. Angiogram was then performed. This showed

much improved flow. There appeared to be spasm both anterior tibial and

peroneal arteries. The flow was much brisker. The posterior tibial artery

did not fill. The 6-French sheath was inserted in the iliac artery, and an

angiogram was performed.

In an oblique view, there appeared to be

approximately 80% stenosis of the right proximal external iliac artery at its

origin. We placed 6-mm x 17-mm Express LD stent here at 8 atmospheres.

Completion angiogram showed much improved results. However, there was diffuse

narrowing of the external iliac artery, between 40% and 60% throughout. It

was difficult to ascertain, whether this was spasm or not and therefore, I

performed balloon angioplasty using a 5-mm x 100-mm balloon up to 10

atmospheres for 2 minutes. Completion angiogram showed excellent results and

there was excellent outflow present. At this time, I performed extensive

endarterectomy of the common femoral artery with good distal endpoints in the

very proximal superficial femoral artery, as well as the very proximal common

femoral artery. Bovine pericardial patch was brought in the field and sewn in

place using running 6-0 Prolene. Routine flushing maneuvers were carried out.

Continuous wave Doppler showed strong biphasic signals in the proximal

superficial femoral artery and popliteal artery.

Thrombin-soaked Gelfoam was

placed around the patch, and #19 round Blake drain was brought out. The

inferior aspect incision sewn in place with heavy nylon. Hemostasis was

excellent. Groin wound was closed in 3 layers of 2-0 Vicryl and 3-0 Vicryl.

Skin was closed with staples. Dressings were applied. Estimated blood loss

100 cc. Sponge, needle and instrument counts were correct at the end of the

procedure. The patient's foot was very warm and pink at the end of the case.

He had a very strong monophasic signal at the right posterior tibial artery.

I could not hear signal in the right dorsalis pedis artery, but there was a

weaker monophasic signal in the anterior tibial artery. At this time, I was

happy with the results. The patient was sent to recovery room in stable

condition.

Thrombectomy