I'm not sure the correct cpt codes to use for the following procedures, please help
35302, 34201, 35876, and 35371
1. Redo aortofemoral bypass.
2. Redo left profundoplasty.
3. Remote endarterectomy, left superficial femoral artery.
4. Right common femoral artery embolectomy.
5. Left common femoral artery embolectomy.
6. Aortogram with bilateral lower extremity runoff with supervision and interpretation. Selective
catheterization of aorta and left femoral from right femoral access site.
7. Thromboembolectomy of the abdominal aorta.
8. Thromboembolectomy of the right and left limb of the aortofemoral bypass graft.
9. Endarterectomy and bovine Patch angioplasty of the left femoral artery
10. Endarterectomy and bovine Patch angioplasty of the right common femoral artery.
A 58-year-old male with a remote aortofemoral bypass which is now occluded. The left common femoral,
superficial femoral and popliteal arteries are occluded, and limb threatening situation of the left leg. The right lower extremity circulation preoperatively was intact and postoperatively was a normal physical
examination and angiography. On the left leg, successful redo bypass was performed with a thromboendarterectomy, and patch angioplasty with restoration of flow and patency via the profunda
femoris artery and proximal superficial femoral artery. The patient's left popliteal artery remains occluded, but a three-vessel runoff is present to the left foot.
PROCEDURE IN DETAIL
After informed consent was obtained, the patient was taken to the operative suite, and prepped and
draped in usual sterile fashion. Longitudinal incision was made in the previously scarred left groin.
Skin and subcutaneous tissues were divided sharply. Extensive scarring was encountered, and the
dissection was quite difficult but was successfully performed. The left aortofemoral bypass graft was
exposed, very well incorporated. The native common femoral, external iliac, superficial femoral, and
profunda femoris arteries were all encircled. Initially when the bypass graft was exposed, it was
obviously occluded. Exposure of the native vessels occluded over an hour. By the time the dissection was
completed, there was obvious flow in the previously occluded bypass graft. It was not normal, but flow
was seen which was surprising, but encouraging, and decision was made to try to attempt to open the
previous thrombosed graft. Systemic heparin was administered and allowed to circulate. The iliofemoral
arteries and the left profunda and branches as well as superficial femoral arteries were all controlled.
A long arteriotomy was made from the hood of the aortofemoral bypass graft into the profunda femoris
artery and into the superficial femoral artery. The problem in this case was complete occlusion of the
origin of the superficial femoral artery. In fact, the entire superficial femoral artery was small and
relatively atretic. The origin of the profunda femoris artery was also occluded and that was the
etiology of bypass graft occlusion. This was readily appreciated. Upon opening the bypass graft, there
was still flow present in it, and decision was made to proceed with a thrombectomy of the occluded
bypass graft. Copious amounts of organized thrombus were removed. The thrombus was relatively
nonadherent to the bypass graft, implying some flow through it still present. The entire bypass graft
was cleared with multiple Fogarty catheters. With concern for outflow, decision was made to proceed with
a remote endarterectomy of the superficial femoral artery. The superficial femoral artery plaque was
circumferentially dissected, and a small ring cutter could be passed all the way down to, but not
beyond, the popliteal artery. Long segment of plaque was removed from the superficial femoral artery,
and completion angiogram was done showing excellent result of the superficial femoral artery, but
persistent occlusion of the popliteal artery, fairly long segment. Multiple attempts were then done to
try to cross the occluded popliteal artery; however, this was unsuccessful. At this point, with a very
large and developed profunda femoris artery and known 3-vessel runoff to the left foot, decision was
then made to proceed with revascularization via the profunda collaterals to the left foot. Excellent
inflow was now present, and angiogram showed no residual thrombus in the bypass graft. Bovine
pericardial patch angioplasty was done. The common femoral artery bifurcation was enlarged with the
posterior wall of the superficial femoral and profunda femoris artery supplies, and anteriorly a large
patulous anastomosis was created with the bovine pericardial patch and running 5-0 Prolene suture. More
proximally, the bovine patch was sutured to the previous aortofemoral bypass graft and the native common
femoral artery. Circulation to the profunda femoris artery was reestablished, and now there was an
excellent pulse in the profunda femoris artery, and completion angiogram was done showing great flow via
the patent bypass graft to the profunda femoris collaterals and reconstituting the distal below-knee
popliteal artery and 3-vessel runoff. Happy with the results at this time, hemostasis was meticulously
assured, and a 10 mm flat drain was left and the groin incision was closed in layers with Monocryl
sutures. At this time, the examination showed that the patient had no femoral pulse on the right, where
a normal femoral pulse was present prior to the procedure in that location. Therefore, a vertical right
groin incision was made. Division of the skin and subcutaneous tissues was performed. The femoral
triangle was dissected. The common femoral, superficial femoral, profunda femoris arteries were exposed.
Long longitudinal arteriotomy was made, given significant disease in that location, and a 5-French
sheath was placed antegrade with no stenosis at the superficial femoral, popliteal, or tibial arteries.
No stenosis at the profunda femoris artery. Pigtail catheter was then placed to the level of the
juxtarenal abdominal aorta, and power injection technique was used to better delineate the anatomy.
Supervision and interpretation of the images showed patency of the infrarenal abdominal aorta and renal
arteries at the level of the aorta femoral bypass. The left limb of the aortofemoral bypass was widely
patent; however, on the right limb of the aortofemoral bypass, there was now a large thrombus. The
patient has flow in the right internal iliac artery and external iliac artery; therefore, it was
concerning to do a thrombectomy from the right femoral access due to hypermobility to embolize that
right internal iliac artery with the left internal iliac artery already occluded. Decision at this point
was made by placing a 22-French Cook sheath up to and above the area of the right common iliac artery
bifurcation, and opened the wire. Fogarty balloon catheter was advanced up above the aortofemoral
bypass, which is where the thrombus was located, and then the thrombus was pulled into the 24-French
sheath and the 24-French sheath was removed. Now, pulsatile flow was present with normal completion
angiogram going to the right leg; however, some of the thrombus embolized through the patent left
aortofemoral bypass and was occluding flow to the profunda and the superficial femoral arteries. The
thrombus lodged at the common femoral artery bifurcation. The thrombus measured approximately 3 cm in
diameter. Decision was then made to reopen the left groin and perform a thrombectomy of the left common
femoral artery. This was done by opening the previously placed patch in longitudinal fashion because of
the large size of the thrombus and the long patch present. This was quite easily performed. Thrombus was
easily extracted. There was good back bleeding from the superficial femoral and profunda femoris
arteries, and there was excellent inflow through the aorta femoral bypass. No residual thrombus was
present. The patch was reapproximated with 2 layers of 5-0 Prolene sutures, reestablishing good
circulation to the left leg. On the right, bovine pericardial patch angioplasty was similarly performed
to treat the disease at the level of the common femoral artery bifurcation and continue patency and good
flow through the profunda femoris and superficial femoral arteries. 5-0 Prolene sutures were used for
the bovine pericardial patch angioplasty on the right common femoral artery in a running fashion.
Completion angiogram was done showing brisk flow through the aorta, down the aorta femoral bypass,
down the left leg, and normal circulation to the right leg with a palpable pedal pulse on the right foot. On the left foot, given the popliteal artery's persistent occlusion, no palpable pulse was present, but
good flow was now documented via profunda collaterals. Satisfied with the results, all the catheters and
wires were removed. A 10 mm flat Jackson-Pratt drain was left in both groins, and the incisions were
once again closed with layers of 2-0, 3-0 and 4-0 Monocryl sutures. Sterile dressings were applied. The
patient was taken to recovery room in stable condition. Blood loss for the operation was around 1600 mL,