CPT® Code 35005

1. Indications

The procedure described by CPT® Code 35005 is indicated for the surgical repair of the following conditions:

• Aneurysm - An abnormal enlargement or dilation of the vertebral artery.
• Pseudoaneurysm - A hematoma that forms in communication with the arterial wall, typically resulting from trauma or procedural complications.
• Associated occlusive disease - Conditions that may accompany the aneurysm or pseudoaneurysm, affecting blood flow in the vertebral artery.

2. Procedure

The procedure for CPT® Code 35005 involves several critical steps to ensure the effective repair of the vertebral artery.

• Step 1: Incision and Access - The surgical approach begins with an incision, typically in the arm or neck, to access the vertebral artery. If a saphenous vein graft is required, the lower leg is prepped, and the vein is harvested. For proximal vertebral artery repair, a supraclavicular incision is made, which may require division of the clavicle to gain access to the anterior scalene muscle. Care is taken to protect the phrenic nerve during this dissection.
• Step 2: Exposure of the Vertebral Artery - The surgeon carefully dissects through the soft tissues to expose the vertebral artery. This may involve detaching the sternocleidomastoid muscle from the mastoid process for distal repairs, or retracting the mandible for an anterior approach. The dissection is performed meticulously to preserve surrounding structures, including the parotid gland and facial nerves.
• Step 3: Clamping and Opening the Aneurysm Sac - Once the vertebral artery is fully exposed, clamps are applied to the artery and its segmental branches as needed. The aneurysm sac is then opened, allowing for the removal of thrombus and plaque that may be present within the sac.
• Step 4: Repair Techniques - The walls of the artery are sutured to repair any damage. Depending on the specific case, an autogenous (saphenous vein) or synthetic patch graft may be applied. Alternatively, the aneurysm may be excised, followed by direct repair through end-to-end anastomosis of the vessel ends, with or without a patch graft. Another option is the insertion of a tube graft, which involves making a longitudinal incision in the artery, inserting the graft, and suturing it to the healthy artery both distal and proximal to the aneurysm.
• Step 5: Closure and Restoration of Blood Flow - After the repair is completed, the aneurysm sac is closed over the graft, and the clamps are released to restore normal blood flow through the vertebral artery.

3. Post-Procedure

Post-procedure care for patients undergoing the repair of a vertebral artery aneurysm or pseudoaneurysm typically includes monitoring for complications such as bleeding, infection, or neurological deficits. Patients may require imaging studies to assess the success of the repair and ensure that blood flow has been adequately restored. Recovery may involve pain management and rehabilitation to regain strength and function, particularly if there was significant manipulation of surrounding tissues or nerves during the procedure. Follow-up appointments are essential to monitor the patient's progress and address any concerns that may arise during the healing process.