Forum - Questions & Answers

Nov 2nd, 2015 - JBTOOLEY0723 3 

Vascular Op Note...Need Help Coding

I have been out of the industry for a while and could really use some help coding this operative report. Any help would be greatly appreciated.

I currently have:



Pre-procedure Diagnosis: Acute right lower extremity ischemia with ultrasound evidence of popliteal artery occlusion

Post-procedure Diagnosis: same as pre-op diagnosis

Procedure Performed:
1. Exposure of infrageniculate popliteal artery
2. Forgarty thrombectomy of popliteal artery
3.Fogarty thrombectomy of posterior tibial artery
4. Fogarty thrombectomy of peroneal artery
5. Angiogram of tibial arteries
6. Bovine patch angioplasty of popliteal artery

Anesthesia: General

Surgeon: Benjamin, Makamson
Assistant(s): none

Operative Narrative:
The right lower extremity was prepped and draped and an incision was made below the right knee to expose the popliteal artery. Vessel loops were placed proximally and distally and 3000 units of heparin was given prior to the arteriotomy. Thrombus was visualized and it was extracted with a right angle then fogarty catheter was passed proximally until pulsatile flow was restored then distally down the tibial arteries until back bleeding occured. An angiogram was then performed confirming flow to the foot via the peroneal and posterior tibial arteries. The anterior tibial artery is likely chronically occluded. A bovine patch was used to patch the popliteal artery. A #19 Round Blake drain was placed through a separate stab incision. The incision was closed with layered -0 Vicryl and skin staples.

Specimens: thrombus

Estimated Blood Loss: 150 ml

VTE Prophylaxis: Contraindicated due to: type of surgery or procedure

Disposition: ICU

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