CPT® Code 33690

1. Indications

The procedure of pulmonary artery banding (PAB) is indicated for specific congenital cardiac defects that result in left-to-right shunting and excessive pulmonary blood flow. The following conditions are commonly associated with the need for this intervention:

• Congenital Heart Defects Conditions such as ventricular septal defects (VSD) or atrioventricular septal defects (AVSD) that lead to increased blood flow to the lungs.
• Pulmonary Overcirculation Situations where there is an excessive volume of blood flowing into the pulmonary circulation, which can cause complications such as pulmonary hypertension.
• Prevention of Hypertrophy The need to prevent hypertrophy of the pulmonary vasculature, which can occur due to chronic overcirculation.
• Management of Pulmonary Hypertension Cases where there is a risk of developing irreversible pulmonary hypertension due to excessive blood flow.

2. Procedure

The procedure of pulmonary artery banding involves several critical steps to ensure proper placement and function of the band:

• Step 1: Surgical Access The procedure begins with the patient being positioned for surgery, followed by an incision made through an anterior left thoracotomy in the second or third intercostal space, or alternatively, a median sternotomy may be performed to access the thoracic cavity.
• Step 2: Pericardial Incision The pericardium is incised anterior to the left phrenic nerve, allowing for the retraction of the thymus to provide a clear view of the main pulmonary artery and aorta.
• Step 3: Exposure of Vessels The main pulmonary artery and aorta are carefully exposed to facilitate the subsequent steps of the procedure.
• Step 4: Band Circumference Estimation The surgeon estimates the required circumference of the band that will be placed around the pulmonary artery to regulate blood flow effectively.
• Step 5: Dissection for Band Placement The site for band placement is selected in the mid-portion of the main pulmonary artery, and the adventitia between the aorta and the main pulmonary artery is dissected at this site to allow for band placement.
• Step 6: Band Placement The band is passed through the transverse sinus, encircling both the aorta and the main pulmonary artery, and is then delivered between the two vessels at the dissection site.
• Step 7: Snaring and Fixation The band is snared and fixed in place using hemoclips to ensure it remains securely positioned around the pulmonary artery.
• Step 8: Pledget Placement A felt or pericardial pledget is placed beneath the snare and the main pulmonary artery to provide additional support and stability to the band.
• Step 9: Band Tightening The band is tightened to achieve the desired level of constriction, which will help regulate blood flow to the lungs.
• Step 10: Monitoring After band placement, pulmonary artery pressures, systemic blood pressure, and arterial oxygen saturation are monitored to ensure they are within desired limits.
• Step 11: Closure Once optimal pressures and oxygen saturation levels are achieved, chest tubes are placed as necessary, and the surgical incisions are closed to complete the procedure.

3. Post-Procedure

Following the pulmonary artery banding procedure, patients are typically monitored closely for any complications and to assess the effectiveness of the banding. Post-operative care may include monitoring vital signs, including pulmonary artery pressures and oxygen saturation, to ensure they remain stable. Patients may require pain management and support for respiratory function, including the use of chest tubes if placed during surgery. The recovery period will vary based on individual patient factors and the complexity of the procedure, but the goal is to ensure that the pulmonary blood flow is adequately regulated and that the patient is progressing towards recovery without complications.