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little confused on this one...pt has had tpa infusion done on the 11th, a follow-up and cath. change on the 12th, and now back again on the 13th...following this procedure on the 13th the pt. was taken for open graft thrombectomy in the OR...for this portion below I was thinking 75898/75900/37209. Not 100% though...i'm not quite sure if the cath. was actually exchanged or not. When the OR surgeon gets the pt. to the OR he mentions in his note that the infustion cath. was removed prior to the thrombectomy. your thoughts? thanks! PREOPERATIVE DIAGNOSIS: Thrombosis of left femoral-to-posterior tibial bypass. POSTOP DIAGNOSIS: Thrombosis of left femoral-to-posterior tibial bypass. OPERATION PERFORMED: 1. Angiogram of left lower extremity. ANESTHESIA: Local plus sedation. ESTIMATED BLOOD LOSS: Less than 5 mL. INDICATION: Mr. XXX is a 72-year-old gentleman who initially had presented with thrombosis of his left femoral-to-posterior tibial bypass graft. An angiogram of left lower extremity was obtained and catheter directed thrombolysis was initiated. 24 hours later, repeat angiogram revealed patent bypass graft, but distal posterior tibial artery remained occluded. Thrombolysis was continued. Today, he was brought again to the operative room for the reevaluation of his left lower extremity. OPERATION: After informed consent was obtained, the patient was brought to the operating room and placed in the supine position. Conscious sedation was achieved by anesthesiologist. Patient's bilateral lower extremities were prepped and draped in a standard surgical fashion. At this point of time, the wire of the Infusi-Catheter was removed. It appeared that there was a significant amount of thrombus attaached to the wire of Infuse-A-Catheter. Manual aspiration was done on the Infuse-A-Catheter which also revealed clotted blood. At this point of time, decision was made not to give any dye through the Infuse-A-Catheter because of the risk of showering emboli into distal perfusion. The Infuse-A-Cath was then removed. Aspiration was done on the sheath which revealed good arterial blood. It was flushed adequately with heparinized saline. A diagnostic angiogram of the left lower extremity was performed through the sheath which showed that the previously open femoral-to-pop bypass was thrombosed again. There was no blood flow into the bypass at all. The angiogram also revealed that there was a significant collaterals both in the thigh and calf which were patent. At this point of time, an 0.35 Glidewire was passed through this sheath successfully into the bypass and across distal anastomosis into the native posterior tibial artery. A Quick-Cross catheter was then placed into the native posterior tibial artery. Aspiration revealed good arterial blood. Repeat handheld contrast was given which showed that the distal posterior tibial artery was patent. At this point of time, the options were either to continue thrombolytic therapy through this graft or to do an open cut down and thrombectomy of the bypass. Since the patient has already received about 48 hours of thrombolytic therapy with re-thrombosis a decision was made to proceed with open thrombectomy. Dr. XXX was present inside the operating room and open thrombectomy was performed under guidance of Dr. XXX. This procedure will be dictated separately by Dr. XXX. here's the beginning of the surgeon's note: OPERATION: The angiography portion of the patient's care is being dictated separately by Dr. Aziz. I was called to the operating room to consult on the patient. Patient was receiving light conscious sedation and monitored anesthesia care. He was prepped and draped in the supine position on the fluoroscopy table in OR 25. Angiography done minutes earlier had shown that the graft was rethrombosed. However, an angiogram done through the tip of the infusion catheter showed that the runoff vessels were in fact patent, at least to the ankle. At this point, I scrubbed into the case. The cause for rethrombosis of the graft was not clear, but we were concerned that perhaps the infusion catheter had malfunctioned. Earlier in the morning, the patient had a palpable pulse and signals in the graft, but in the OR, the graft was thrombosed. Rather then reinitiate or continue the thrombolytic infusion, I felt that it would be appropriate to cut down on the graft and do a catheter thrombectomy. If this did not work, there really was nothing else surgically that could be done. We asked anesthesia team to induce general anesthesia, which was done with an endotracheal tube. The entire leg was already prepped and draped. A short transverse incision was made over the distal thigh portion of the graft. This did not provide adequate exposure of the graft and so we made a separate longitudinal incision just at about the level of the knee joint. The graft was pulseless, but was palpable because of the infusion catheter in it. After an appropriate length of graft had been isolated, we removed the infusion catheter from the right-sided 5 French sheath. At this point, the graft was soft and compressible but pulseless. The patient was bolused with heparin to achieve an ACT over 220 seconds. Control of the pulseless graft had been obtained. We made a small transverse arteriotomy in the graft. We passed a #3 Fogarty catheter proximally. The catheter passed without resistance well up into the external iliac artery. We extracted a large amount of fresh, red thrombus and this was followed by a pulsatile inflow. An additional pass of the catheter did not yield any further thrombus. We instilled heparin saline liberally into the upper part of the graft. The distal thrombectomy was done with a #2 Fogarty catheter, which again passed without resistance, all the way to the ankle and slightly beyond. We withdrew the catheter and again retrieved fresh, dark thrombus. This did not appear to be platelet fibrin thrombus. Two more passes were done with minimal additional material retrieved and we now had bright red backbleeding. Heparin saline and low-molecular weight dextran were instilled distally.