Groin Sheath and Impella procedure

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Joined: Sat Dec 20, 2014 9:32 pm

Thu Mar 21, 2019 10:58 am

Hello! Thank you in advance for any help.

We are trying to determine what is the correct CPT code(s) for this case copied below.

The physician feels it should be the artery repair because this is not the usual way of removing the sheath. CCI shows 33992 (removal of impella) as major procedure with the artery repair (35226) bundled. Is there something he needs to call out that is not typical of the impella procedure?




ANESTHESIA: General endotracheal.

PREOPERATIVE ANTIBIOTICS: Two grams of Ancef were infused within 30 minutes of incision time.
DVT prophylaxis. The patient was fully anticoagulated on argatroban.



DRAINS: A 19-French Blake drain placed in the right groin incision.

COUNTS: Instrument and gauze counts were correct at the end of the case.

PREOPERATIVE DIAGNOSIS: Large right groin sheath with high risk for regular manual pull.

POSTOPERATIVE DIAGNOSIS: Large right groin sheath with high risk for regular manual pull.

PROCEDURE: Right groin exploration, removal of a right groin sheath and Impella device. Primary repair of the right External iliac artery.

FINDINGS: There was a large diameter sheath in the right distal external iliac artery with Impella device inside of it at. small hematoma at the access site. The artery was found to have healthy edges and was closed primarily. No bleeding at the end of the case. Doppler signals over the right DP and PT at the end of the case.

INDICATION(S): Mr. is a -year-old who presented to Hospital with cardiac arrest on 02/25/2019, after which underwent cardiac catheterization with Impella device placement via Rt groin access. has had the large right groin sheath and the impala device sine then. Post-intervention,was noted to have low platelet count of 40,000s with suspicion for HITT and is on dual antiplatelet therapy for cardiac stent which was recently placed, was deemed high risk for regular manual pull of the sheath and the Impella device with ProGlide application, so he was taken to the OR for exploration of the sheath and primary repair of the artery.

DESCRIPTION OF PROCEDURE: The patient was placed in supine position. Bilateral lower extremities were prepped and draped in standard surgical fashion using chlorhexidine. The timeout was performed as per the World Health Organization and Institutional Guidelines and then an incision was made in the right groin. The incision included the access site for the right groin sheath. The underlying tissue was dissected and the common femoral artery was identified and dissected in a Standard surgical fashion. The sheath was identified in place in the distal external iliac artery and through the inguinal ligament. The inguinal ligament around the sheath was dissected and the external iliac artery above the sheath was dissected in standard surgical fashion. The right superficial femoral artery and profunda femoris artery were then dissected in a standard surgical fashion. All arteries were found to be soft. The patient was then bolused with argatroban as per pharmacy dosing and then the external iliac artery, superficial femoral artery and the PFA were controlled using clamps and the sheath was removed. The whole in the external iliac artery was found to be less than 50% of the diameter. There was satisfactory back bleeding from the SFA and PFA with no clots inside the arterial lumen. The artery edges were refreshed and the arteriotomy was closed using interrupted 6-0 Prolene sutures. The closure was found to be hemostatic with no active bleeding. The incision was examined and hemostasis was assured using clips and electrocautery as appropriate. The first layer of the incision was closed using 2-0 Vicryl and then a 19-French drain was placed in the wound. The inguinal ligament was closed using 2-0 Vicryl and the rest of the layers were closed using 2-0 and 3-0 Vicryl and skin staples for the skin. The patient tolerated the procedure well. There was no bleeding at the end of the case and the patient was transferred in stable condition to the CVCU.

Electronically signed by , MD at 03/05/19 0856

Thank you again,
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