Question

PREOPERATIVE DIAGNOSES: Right carotid stenosis

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE PERFORMED: Right carotid thromboendarterectomy.

This patient was monitored with EEG. There were some depressions when we clamped, but this returned to normal after

re-establishing circulation.

ANESTHESIA: General

DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient’s right side of the neck was prepped and draped in

the usual manner. An incision was made across the medial border of the sternocleidomastoid. The platysma was divided. The

common carotid artery was localized. We then put a LigaLoop around it, and then we isolated the external and internal carotid

arteries and placed LigaLoops around them. We saw the hypoglossal nerve. We put the retractors in and retracted on the

upper end of the wound, and then we gave the patient heparin and proceeded with the arteriotomy.

After placing clamps on the internal, common, and external carotid arteries, the arteriotomy was done. This was a severe

stenosing atherosclerotic plaque. This was removed. We then sutured the artery up with a 5-0 Prolene at the distal and then

at the proximal and meeting in the middle, producing back bleeding, and then we closed the artery. The wound was then

closed in layers after placing a Hemovac in the wound. The wound was approximated with 2-0 chromic, 2-0 plain, and

surgical staples on skin. A dressing was applied. Patient tolerated the procedure well and was transferred to the recovery

room in stable condition.

Pathology Report Later Indicated: Atherosclerotic plaque. Evacuated clot material.

ICD 10, CPT code needed

Answer 1

The above scenario of the patient condition explains the condition of right carotid stenosis and the procedure performed is carotid thromboendarterectomy through incision by neck and the CPT code is 35301.