Hemodynamic conditions in a failing peripheral artery bypass graft

Abstract

An arterial bypass graft may develop a hemodynamically significant stenosis at either anastomosis (proximal or distal), within the body of the graft, or in the native arterial inflow/outflow separate from the reconstruction. Operative repair may include jump grafting, patch angioplasty, endarterectomy, or interposition bypass. In this review, issues after inflow reconstruction (eg, aortofemoral, iliofemoral, crossfemoral, or axillofemoral) will be addressed. Narrowing at the femoral outflow anastomosis may be treated by standard patch angioplasty. Reporting such an endeavorisbasedonthetypeofpatchemployed.CPTcode 35883 (Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with nonautogenous patch graft [eg, Dacron, ePTFE, bovine pericardium]) denotes use of nonautogenous material, while CPT code 35884 (Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with autogenous vein patch graft) requires the surgeon implant a piece of vein harvested from the same incision or through a separate exposure. These codes are reported only when no femoral endarterectomy is performed. The reoperative bypass CPT code 35700 is not additionally reported. When the femoral plaque burden is too great for treatment using a standard patch, common femoral (CPT code 35371), superficial femoral (CPT code 35302), or deep femoral (CPT code 35372) endarterectomy may be performed in the treatment of occlusive disease. The code description states “thromboendarterectomy, including patch graft, if performed.” Therefore, patch closure of the vessel with either prosthetic or autogenous material is bundled with the endarterectomy. Clot extraction either directly or by use of embolectomy catheters through the same arteriotomy is also inherent. Lastly, the reoperative bypass CPT code 35700 is not additionally reported. Jump grafting may be required to preserve outflow when direct repair is not appropriate or desired. Bypass from the “femoral graft” to the native femoral artery (common, superficial, or deep) is a femoral-femoral bypass. When performed with prosthetic conduit, CPT code 35661 (Bypass graft, with other than vein; femoral-femoral) is reported. When vein is employed, CPT code 35558 (Bypass graft, with vein; femoral-femoral) is more fitting. Note than these two codes are each appropriate for contralateral (eg, cross-femoral bypass) or ipsilateral arterial reconstructions. Again, the reoperative bypass CPT code 35700 is not additionally reported. If the outflow bypass requires a more distal target, standard infrainguinal bypass graft coding is appropriate. For example, a reconstruction anastomosed to the hood of the prosthetic graft at the “femoral” level proximally and run distally to the popliteal artery qualifies as “femoral-popliteal” for coding purposes. See the prior CPT Advisor article on bypass coding for details. 1 If an aneurysm or pseudoaneurysm develops in the groin at the distal anastomosis, operative repair may involve resection of a portion of the artery, resection of the distal prosthetic conduit, and implantation of an interposition graft between the two. CPT code 35141 (Direct repair of