CPT® Code 35623

1. Indications

The axillary-popliteal or axillary-tibial bypass graft procedure is indicated for patients experiencing significant vascular obstruction or disease that impairs blood flow in the aorta, iliac, or femoral arteries. The following conditions may warrant this surgical intervention:

• Peripheral Artery Disease (PAD) - A condition characterized by narrowed arteries reducing blood flow to the limbs, often leading to pain and mobility issues.
• Critical Limb Ischemia - A severe obstruction of the arteries that significantly reduces blood flow to the extremities, potentially resulting in pain at rest, ulcers, or gangrene.
• Aneurysms - Abnormal bulges in the arterial wall that may require bypass to prevent rupture or further complications.
• Trauma - Vascular injuries resulting from accidents that necessitate the rerouting of blood flow to maintain limb viability.

2. Procedure

The procedure for an axillary-popliteal or axillary-tibial bypass graft involves several critical steps to ensure successful rerouting of blood flow. The following outlines the procedural steps:

• Step 1: Incision and Exposure - A skin incision is made in the chest, just below the clavicle, to access the proximal axillary artery. Soft tissue is carefully dissected to expose the artery adequately. A second incision is then made in the groin area over the common femoral artery or in the leg over the popliteal or tibial artery, allowing for the necessary exposure of these arteries.
• Step 2: Creating the Tunnel - A tunnel is created that begins at the exposed axillary artery and extends down through the chest and abdomen, passing under the inguinal ligament. This tunnel will terminate at the exposed section of the common femoral artery for an axillary-femoral bypass. If an axillary-popliteal or axillary-tibial bypass is being performed, the tunnel is extended further along the leg to reach the exposed section of the popliteal or tibial artery.
• Step 3: Graft Preparation - An appropriately sized tubular synthetic graft is selected based on the dimensions required for the bypass. The graft is prepared for implantation.
• Step 4: Graft Attachment - Vascular clamps are applied to the axillary artery, and an incision is made in the artery. The synthetic graft is then sutured to the axillary artery securely. Following this, the graft is passed through the previously created tunnel.
• Step 5: Distal Attachment - The common femoral, popliteal, or tibial artery is clamped and incised, and the graft is sutured to this artery as well, ensuring a secure connection for blood flow.
• Step 6: Final Checks - After the graft is in place, the vascular clamps are removed. Blood flow through the graft is assessed using Doppler ultrasound, and distal pulses are evaluated to ensure the patency of the bypass graft.

3. Post-Procedure

Post-procedure care for patients undergoing an axillary-popliteal or axillary-tibial bypass graft includes monitoring for any signs of complications, such as infection or graft failure. Patients are typically observed for adequate blood flow to the lower extremities, and pain management is provided as needed. Follow-up appointments are essential to assess the graft's patency and overall vascular health. Patients may also be advised on lifestyle modifications and rehabilitation exercises to promote recovery and improve circulation.