CPT® Code 35535

Official Description

Bypass graft, with vein; hepatorenal

Common Language Description

A hepatorenal vein bypass graft is a surgical procedure designed to create a new pathway for blood flow around a diseased or obstructed segment of the renal artery, which supplies blood to the kidney. This procedure is essential for restoring adequate blood circulation to the kidney, thereby preventing potential damage due to ischemia. The surgery involves making an incision in the abdomen to access the necessary anatomical structures. During the operation, the omentum, a fold of peritoneum extending from the stomach, is separated from the transverse colon to expose the celiac axis, which includes critical arteries such as the hepatic, left gastric, and splenic arteries. The common hepatic artery is then isolated to facilitate the grafting process. The descending duodenum is mobilized to provide better access to the inferior vena cava and renal vein, which are crucial for the procedure. The inferior vena cava is carefully mobilized, and the renal artery is isolated to prepare for the grafting. A vein graft, typically harvested from the saphenous vein in the leg, is prepared for use. The harvesting process involves making an incision over the selected section of the saphenous vein, dissecting the soft tissue, and ligating the vein's branches before removing the vein segment. Once the graft is ready, vascular clamps are applied to the hepatic artery, which is then incised. The vein graft is sutured in an end-to-side configuration to the hepatic artery, establishing a new route for blood flow. Following this, the renal artery is clamped and incised, and the vein graft is anastomosed in an end-to-side manner to bypass the obstructed area of the renal artery. After ensuring proper placement, the clamps are released, and the blood flow through the graft is verified using Doppler ultrasound, confirming the success of the procedure in restoring blood supply to the kidney.

1. Indications

The hepatorenal vein bypass graft procedure is indicated for patients who present with specific conditions affecting the renal artery. These indications include:

Obstructed Renal Artery - The procedure is performed when there is a blockage in the renal artery that impedes blood flow to the kidney, potentially leading to renal ischemia.
Renal Artery Stenosis - This condition involves the narrowing of the renal artery, which can result in hypertension and kidney dysfunction, necessitating surgical intervention to restore normal blood flow.
Renal Ischemia - Patients experiencing reduced blood supply to the kidney due to vascular issues may require this bypass graft to prevent further renal damage.

2. Procedure

The hepatorenal vein bypass graft procedure involves several critical steps to ensure successful grafting and restoration of blood flow. The steps are as follows:

Step 1: Incision and Exposure - The procedure begins with an incision in the abdomen to access the necessary anatomical structures. The omentum is carefully separated from the transverse colon, allowing for the exposure of the celiac axis, which includes the hepatic, left gastric, and splenic arteries.
Step 2: Isolation of the Common Hepatic Artery - The common hepatic artery is isolated to facilitate the connection of the vein graft. This step is crucial for ensuring that the graft can be properly sutured to restore blood flow.
Step 3: Mobilization of the Descending Duodenum - The descending duodenum is mobilized to provide better access to the inferior vena cava and renal vein, which are essential for the grafting process.
Step 4: Identification of the Inferior Vena Cava and Renal Vein - The inferior vena cava is located and mobilized, and the renal artery is isolated to prepare for the grafting procedure.
Step 5: Harvesting the Vein Graft - A vein graft is harvested, typically from the saphenous vein in the leg. An incision is made over the section of the saphenous vein to be used, and the surrounding soft tissue is dissected. The branches of the vein are ligated and divided, and the selected section of the vein is ligated proximally and distally, divided, and removed from the leg.
Step 6: Clamping and Incising the Hepatic Artery - Vascular clamps are applied to the hepatic artery, which is then incised to prepare for the attachment of the vein graft.
Step 7: Suturing the Vein Graft - The vein graft is sutured in an end-to-side configuration to the hepatic artery, establishing a new pathway for blood flow.
Step 8: Clamping and Anastomosing the Renal Artery - The renal artery is clamped and incised, and the vein graft is anastomosed in an end-to-side manner to bypass the diseased or obstructed portion of the renal artery.
Step 9: Releasing Clamps and Checking Blood Flow - After the anastomosis is complete, the clamps are released, and blood flow through the graft is checked using Doppler ultrasound to ensure that the procedure has successfully restored circulation to the kidney.

3. Post-Procedure

Post-procedure care for patients undergoing a hepatorenal vein bypass graft includes monitoring for any complications, ensuring proper blood flow through the graft, and managing pain. Patients may require follow-up imaging studies to assess the patency of the graft and the overall function of the kidney. Additionally, healthcare providers will monitor the patient's renal function and blood pressure, as these can be affected by the surgery. It is essential for patients to adhere to any prescribed medication regimens, including anticoagulants, to prevent thrombosis in the graft. Recovery time may vary, and patients should be advised on activity restrictions and signs of potential complications that warrant immediate medical attention.

Short Descr	ART BYP GRFT HEPATORENAL
Medium Descr	BYPASS W/VEIN HEPATORENAL
Long Descr	Bypass graft, with vein; hepatorenal
Status Code	Active Code
Global Days	090 - Major Surgery
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62)	1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Inpatient Procedures, not paid under OPPS
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	P2F - Major procedure, cardiovascular-Other
MUE	1
CCS Clinical Classification	56 - Other vascular bypass and shunt, not heart

This is a primary code that can be used with these additional add-on codes.

35572

Addon Code MPFS Status: Active Code APC N ASC N1 CPT Assistant Article Illustration for Code Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (List separately in addition to code for primary procedure)

51	Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
GC	This service has been performed in part by a resident under the direction of a teaching physician
RT	Right side (used to identify procedures performed on the right side of the body)