Ask Dr. Z

Please tell me how you would code this case? Is there a code for the contralateral limb? or is it included in the 34802. we placed 2 Perclose devices after accessing the right common femoral artery. We then placed a 7 French sheath in each common femoral artery and then advanced an angled guidewire into the right common femoral artery, up into the distal abdominal aorta. With this in place, we then used a 5 French pigtail to perform our first aortogram and runoff. With the first aortogram and runoff, we identified the takeoff of the right and left renals. We did have some overlapping on the left side with the inferior mesenteric artery. It required 2 extra aortograms with 1x magnification to fully delineate the takeoff of the left renal. Once we had this in place, we at this time changed our II to a craniocaudal angle of 15 degrees. With this positioning, we fixed the bed, fixed the II, and then introduced the main body device on the left side over a stiff Amplatz wire. With the main body device introduced, we selected out a 36 x 20 x 166 bifurcated main body device. We advanced this into the distal abdominal aorta just above the renal arteries. Once we were satisfied with this placement, we began the deployment. We deployed the device down to expose the contralateral limb and held it in place. We then took one more selective aortogram at the level of the renal arteries and noted that the device was in good position. We then removed our pigtail from behind the bifurcated device using an angled wire and then exchanged out the pigtail for an FR4 catheter. The FR4 catheter, however, with the angled glide could not be used to cannulate the contralateral gate. We therefore switched the FR4 to an MPA and with the MPA 5 French catheter, we were able to cannulate the contralateral gate with the stiff-angled glide. With this done, we then exchanged out the MPA for a 5 French pigtail. This was brought into what was seen to be the graft body. We were then able to spin the pigtail nicely and then injected approximately 10 cc of contrast. We could see very selective filling of the graft and then down the contralateral limb and then back up into the closed left iliac limb. Satisfied with the placement, we then brought in the contralateral limb. We selected out a 16 x 20 x 124 Endurant contralateral limb. This was positioned nicely over a stiff Amplatz wire and deployed. Once this was completed, we then released the proximal renal fixation and then withdrew our graft on the left side so as to complete the deployment. We then removed our MPA device and brought in a Reliant balloon from the right side. We ballooned proximally. We ballooned the gate and then we ballooned the distal iliac components on the right to obtain a good seal. We then brought the balloon to the left side and again ballooned proximally and distally on the left iliac limb. Once this was completed, we performed our aortogram with runoff. We noted that we had a good proximal seal initially but then had either late, Type 1-A endoleak or a Type 2 endoleak proximally. We had good sealing at the gate and good sealing at the distal iliac limbs. We then brought the balloon back in and inflated once more just above the graft sitting at the renals and then just below it so as to get a much better seal proximally. We felt that with this aggressive ballooning, we optimized our seal and then we repeated our aortogram. We noted a much better control and had a very tiny, Type 2 endoleak from the lumbar artery. With this completed, we then removed our devices, deployed our Perclose sutures, and got good hemostasis. We gave the patient a total of 80 mg of protamine. Of note, during the course of the procedure, we gave him a total of 14,000 units of heparin and had the ACT above 250 at all times. With the completion of the procedure and the administration of the protamine, we checked for pulses. We had good distal pulses. We had no bleeding at our access site.