What Is The Cpt Code For Repair Of Venous Aneurysm

• Journal List
• Ann Vasc Dis
• five.8(1); 2022
• PMC4369571

Ann Vasc Dis. 2022; viii(ane): 56–58.

Surgical Repair for Popliteal Venous Aneurysm Causing Severe or Recurrent Pulmonary Thromboembolism: Iii Example Reports

Togo Norimatsu

Department of Vascular Surgery, Sakakibara Heart Plant, Tokyo, Japan

Haruo Aramoto

Department of Vascular Surgery, Sakakibara Heart Institute, Tokyo, Japan

Received 2022 Sep 22; Accepted 2022 Jan seven.

Abstruse

Poplitealvenous aneurysms (PVA) are associated with deep venous thrombosis and recurrentpulmonary thromboembolism (PE). We report three cases of PVA. In all three patients the first sign of PVA was acute PE; in one instance, the PE was recurrent. Computed tomography and duplex ultrasonography revealed non only PE but also popliteal venous dilatation with thrombus. Surgical reconstruction was performed in each example after treatment for PE. No postoperative complications occurred, including recurrent PE. Surgical repair of PVA is safe and is a recommended treatment.

Keywords: popliteal venous aneurysm, pulmonary thromboembolism, surgical repair

Introduction

Venous aneurysms are uncommon, dissimilar varicose veins caused by valvular dysfunction. Popliteal venous aneurysm (PVA) is potentially life threatening, because it can result in pulmonary thromboembolism (PE). Because the reported risk of recurrent PE is loftier in patients with PVA, even among those receiving anticoagulation treatment, surgical intervention is recommended.¹⁾ We study three cases of PVA treated with surgical reconstruction using different procedures.

Case 1

A 65-year-erstwhile adult female presented with exertional dyspnea. Computed tomography (CT) revealed PE. Venous ultrasonography revealed a thrombosed multilocularsaccular PVA. There was no history of previous venous thrombosis. Anticoagulation therapy was started, and a temporary junior vena cava (IVC) filter (GüntherTulip; Melt Medical, Bloomington, Indiana, U.s.) was inserted. I day later, the patient became hypotensive and lost consciousness. Thrombosis of the pulmonary artery and popliteal vein were unchangedon repeat CT. The patient was intubated and was treated in intensive care for 27 days. In one case her general condition stabilized, nosotros performed surgical treatment for PVA. Lateral venorrhaphy was not possible because of inadequate healthy venous tissue. Aneurysmectomy and patch plasty with the saphenous vein were performed ( Fig. i ).

Case 1. (A) Computed tomography (CT) scan showing multilocular saccular popliteal venous aneurysm (PVA; arrow). (B) Intraoperative view and schema of PVA. (C) Aneurysmectomy and patch plasty with saphenous vein.

Example 2

A 77-year-old adult female presented with palpitations and a history of PE 2 years before. The patient'south IVC filter had been removed, and she had discontinued oral anticoagulation therapy on her own. CT showed PE and a dilated right popliteal vein. Venous ultrasonography demonstrated a multilocularsaccular PVA that had grown over the preceding two years. We initiated anticoagulation therapy afterward IVC filter placement. The patient underwent aneurysm resection with interposed polytetrafluoroethyleneprosthesis (PTFE) 17 days later ( Fig. two ).

Case 2. (A) Duplex browse of multilocular saccular PVA. (B) Intraoperative view of PVA. (C) Aneurysm resection with interposed polytetrafluoroethylenegraft. PVA: popliteal venous aneurysm.

Case iii

A 76-yr-onetime woman presented to another hospital with acute shortness of breath. She was admitted and treated at that place for heart failure. 2 weeks later on, the patient was transferred to our hospital because of hypoxia and hypotension. CT showed PE and deep vein thrombosis. Ultrasonography revealed right PVA and thrombus. A temporary IVC filter (ALN vena cava filter; ALN, Ghisonaccia, France) was placed and tissue-type plasminogen activator was administered, after which the patient's condition markedly improved. The patient electively underwent tangential aneurysmectomy and lateral venorrhaphy ( Fig. iii ).

Case 3. (A) Duplex scan of simple saccular PVA. (B) Intraoperative view of PVA. (C) Tangential aneurysmectomy and lateral venorrhaphy. PVA: popliteal venous aneurysm.

The pathologic findings of the excised tissues were inconsistent with varicose veins. At 21–57-month follow-up, duplex scanning demonstrated deep venous system patency without whatsoever symptoms in all cases.

Discussion

PVA is rare. There have been 212 reported cases since the first report by May and Nisselin 1968.^2,iii) In 1976, Dahl et al. described the showtime case of recurrent PE resulting from PVA.⁴⁾ Co-ordinate to a current review, 24–51% of patients with PVA nowadays with PE. In 55–76% of patients, PVA is associated with chronic venous disease, including superficial vein insufficiency, leg swelling, and venous ulceration.^1,5) Rupture is a rare complication of PVA.⁵⁾ The etiology of PVA remains unknown, and no association with arterial aneurysm has been reported.

Various modalities are available to diagnose PVA, including phlebography, duplex ultrasonography, and computed tomography (CT). Venous duplex scanning is the best noninvasive diagnostic method to appraise lower limb deep vein aneurysm, and to decide aneurysm size and morphology.

Well-nigh PVAs are saccular (72–88% of cases); the remainder are fusiform.^1,6) Thrombus formation within the aneurysmal sac is found in approximately 2-thirds of PVA patents. Although big or saccular aneurysms are more decumbent to thromboembolic complications, there are no size criteria to definitely label a venous fusiform dilatation of an aneurysm. Maleti et al. defined aneurysm as a venous fusiform dilatation >twenty mm, at least three times the size of the normal popliteal vein.^seven)

Anticoagulation therapy alone may not prevent PE in patients with symptomatic PVA, and its sole use every bit treatment is associated with a high incidence of recurrence.^1,3,5,six,8) Given the potential for serious thromboembolic complications, surgical repair is indicated in all symptomatic patients. However, management of asymptomatic PVA remains a controversial issue.

Two instance series take described the class of asymptomatic patients with fusiform and saccular PVAs.^ane) Although untreated, none of these patients experienced thromboembolic events. Yet, the size of the aneurysms was quite small and follow-up was short. Maldonado-Fernandez et al. reported five deaths resulting from PE in patients receiving medical handling for PVA.³⁾ Therefore, regardless of symptoms, most investigators consider surgery is the best treatment for PVA, indicated for all saccular aneurysms and for fusiform aneurysms >20 mm.

PVA does not present with specific, definite signs, or symptoms. Only 20% of reported cases had a palpable mass in the popliteal fossa,^three) making PVA difficult to diagnose in asymptomatic patients. In these cases, there is no need to pursue duplex ultrasonography equally a screening test. Withal, all PE patients should undergo CT phlebography and duplex ultrasonography with PVA in mind. Every bit shown in our iii cases, PE with PVA tin can exist severe or recurrent, and a cure is possible with surgery.

Maldonado-Fernandez et al. reviewed the records of 102 patients who underwent surgical treatment for PVA.³⁾ No mortality, major complications, or repeat thromboembolic events occurred in these patients. Yet, at that place were several modest complications. Early complications, including hematoma, transient nerve injury, infection, and thrombosis of the surgical repair, occurred in 20% of patients. Late complications developed in iv%, including thrombosis from the procedure (one case) and relapse of the venous aneurysm (three cases).

Various operative procedures have been used for venous reconstruction and the incidence of complications varies profoundly according to operation method. Aneurysm resection with preservation of venous continuity is recommended. In particular, tangential aneurysmectomy with lateral venorrhaphyis the preferred technique, because of its lower complication rate compared with other procedures. In contrast, resection of aneurysms with end-to-terminate anastomosis is not considered effective because information technology carries a loftier risk of early on thrombosis.

Only one of our cases was treated with tangential aneurysmectomy with lateral venorrhaphy. Straight suturing was not possible in the other cases considering of inadequate remaining salubrious venous area or large native venous bore. In case 2, the native venous diameter subsequently PVA resection was 10 mm, making it unsuitable for interposition with a saphenous veingraft. More often than not, reconstruction using an autologous graft is the preferred method. Even so, thrombosis has been reported in a patient who received an interposition graft using the internal jugular vein.⁶⁾ Although nosotros considered using a spliced vein graft, we opted for a ringed PTFE graft, which has high antithrombogenicity, is non difficult to use, and is non time- consuming. IVC filter placement is not recommended in electric current American Higher of Chest Physicians or European Society of Cardiology guidelines on PE treatment. Patient 1 deteriorated substantially despite IVC filter implantation. Nosotros could not determine whether new embolization had occured through the filter or pulmonary embolism had progressed. However, preventive IVC filter placement is thought to reduce the risk of embolism during surgical repair of deep vein aneurysm or when thrombosis recurs in the surgical area. All of our patients had acute PE with PVA on admission. The IVC filter was placed to permit subsequent surgery. In case 3, the thrombus disappeared within x days, and the patient did not wish to pursue surgery immediately. Hence, the IVC filter was removed, and surgery was performed approximately 5 months after. Nigh patients receive oral anticoagulation for 3 to 6 months.^one,3,9) However, we recommended permanent employ of compression stockings and oral anticoagulationtherapy with Vitamin Yard adversary to our patients, because all three had severe PE.

Conclusion

PVA is uncommon but can crusade fatal or recurrent PE.Therefore, PVA should be kept in mind in cases of thromboembolism. The nigh effective treatment to prevent PE in patients with PVA is surgical repair rather than anticoagulation therapy.

Disclosure Statement

The authors have no conflicts of interest to report.

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Manufactures from Annals of Vascular Diseases are provided hither courtesy of Editorial Committee of Annals of Vascular Diseases

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369571/

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