Endovascular Aortic Aneurysm Repair (EVAR)
Abdominal aortic aneurysm, [X] cm maximum diameter, anatomically suitable for EVAR
Same
Endovascular abdominal aortic aneurysm repair (EVAR), [device: Endurant / Excluder / Zenith]
[***, MD/DO]
[Resident/PA name]
General endotracheal [/ spinal / MAC with local]
The patient is a [age]-year-old [male / female] with a [X]-cm abdominal aortic aneurysm with anatomy suitable for endovascular repair (infrarenal neck [X] mm diameter, [X] mm length, angulation <60°). EVAR was selected over open repair given [patient comorbidities / patient preference / favorable anatomy]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
Both common femoral arteries were accessed without difficulty. The aortic neck measured [X] mm in diameter with [X] mm length and [X°] angulation. Bilateral iliac fixation zones were adequate. The [Endurant / Excluder / Zenith] endograft was deployed with [no / type I / type II] endoleak on completion angiography.
The patient was positioned supine on the angiography table. Bilateral groin [cutdowns were performed through longitudinal incisions / access was obtained percutaneously]. The common femoral arteries were dissected and controlled with vessel loops [or accessed percutaneously under ultrasound guidance]. Systemic heparin [100 units/kg] was administered and ACT confirmed >250 seconds.
Access was obtained bilaterally and stiff wires [Lunderquist] were positioned in the descending thoracic aorta under fluoroscopic guidance. Sheaths were upsized to accommodate the delivery system [14-22 Fr depending on device]. A [Lunderquist] stiff wire was positioned in the descending thoracic aorta under fluoroscopic guidance. The main body of the [device] endograft was introduced via the [right / left] femoral sheath and advanced to the level of the renal arteries under fluoroscopic guidance. The renal arteries were marked using contrast angiography with a pigtail catheter positioned at the level of the renal ostia.
The main body was deployed with the proximal fixation zone [X] mm below the lowest renal artery. The contralateral limb gate was cannulated from the [left] femoral access, a stiff wire positioned, and the contralateral limb advanced and deployed. The ipsilateral limb was then deployed to the [common iliac / external iliac] artery. Overlap between the main body and limbs was confirmed [≥3 cm].
Completion angiography was performed in [AP / oblique] projection confirming [no endoleak / adequate seal zones / patent renal and hypogastric arteries]. [A type II endoleak from [IMA / lumbar artery] was identified and [embolized / observed].] Sheaths and wires were removed. [Common femoral arteriotomies were repaired with running 5-0 Prolene / Percutaneous closure devices (Perclose ProGlide) were deployed.] Femoral pulses were confirmed. Wounds were closed in layers.
None
None
[X] mL
None
The patient tolerated the procedure well and was taken to the PACU in stable condition. Follow-up CTA scheduled at 1 month and 12 months per SVS EVAR surveillance protocol, then annually thereafter.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: AAA, *** cm, EVAR suitable
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: EVAR, *** device
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: .PTAGE-year-old .PTSEX with *** cm AAA. Neck *** mm × *** mm, *** angulation. EVAR selected given ***. Consent obtained.
FINDINGS: Bilateral CFA access obtained. Neck *** mm, iliac fixation adequate. Completion angio: no endoleak / type *** endoleak.
PROCEDURE:
Supine on angio table. Bilateral femoral [cutdowns / percutaneous access]. Heparin *** units/kg, ACT >250. Stiff wires in descending thoracic aorta. Sheaths upsized to *** Fr. *** device main body deployed *** mm below lowest renal artery. Renal arteries marked with pigtail catheter. Contralateral limb gate cannulated, limb deployed. Ipsilateral limb to ***. Overlap ≥3 cm confirmed. Completion angio: ***. Sheaths removed. [Arteriotomies repaired with 5-0 Prolene / closure devices deployed]. Pulses confirmed. Wounds closed.
EBL: *** mL
COMPLICATIONS: None
DISPOSITION: PACU stable. CTA at 1 month and 12 months scheduled.
Signed: .ME, .MYDEGREE
.TODAYVariants
Type II Endoleak: Embolization vs. Observation
A type II endoleak originating from the [inferior mesenteric artery / lumbar artery] was identified on completion angiography. The aneurysm sac pressure was assessed as low-flow. Option A (embolization): the IMA was cannulated via the SMA collateral pathway and coil-embolized. Option B (observation): the type II endoleak was observed given low-flow character and will be reassessed on 1-month CTA. Type II endoleaks not associated with sac enlargement are observed; those with sac growth at 6-12 months require intervention.
Charting Tips
- Document the proximal seal zone distance from the lowest renal artery. Inadequate neck seal is the most common cause of type I endoleak and late aneurysm rupture. The distance to the renal arteries must be explicitly recorded.
- Document completion angiography findings specifically: endoleak type, renal patency, hypogastric patency, and iliac limb positions. A generic 'no endoleak' statement without documenting renal/hypogastric assessment is insufficient.
- EVAR requires lifelong surveillance. Document the follow-up imaging plan in the operative note per SVS 2018 guidelines: CTA at 1 month, 12 months, then annually. This establishes the surveillance protocol and is a quality metric.
- For open cutdown, document the cutdown separately for each side. For percutaneous access, document sheath size (12 Fr or larger) and the closure device used, since both are required to support the large-sheath closure add-on.
- Aortic aneurysm diagnosis coding depends on location (infrarenal, juxtarenal, or pararenal) and rupture status, and iliac aneurysms are coded separately. Document the aneurysm extent relative to the renal arteries, rupture status, and any iliac involvement.
Documentation & Reimbursement Considerations
- Primary service: Report Endovascular Aortic Aneurysm Repair (EVAR) as the primary service when it is the definitive operation performed.
- EVAR codes are mutually exclusive standalone primary codes chosen by graft configuration: aorto-aortic tube (23.12 wRVU), aorto-uni-iliac (25.86 wRVU), aorto-bi-iliac (28.84 wRVU, the standard bifurcated repair of infrarenal AAA), or ilio-iliac (21.72 wRVU). All carry a 90-day global.
- The rupture-variant EVAR codes (aorto-uni-iliac and aorto-bi-iliac, 43.88 wRVU) apply when temporary aortic and/or iliac balloon occlusion is performed, as in emergency EVAR for rupture. They are NOT revision or redo codes, and using them for elective revision of a prior endograft is a compliance violation. There is no dedicated revision EVAR code, so elective reintervention is coded with the relevant intervention code for the work performed.
- Femoral access add-ons are separately billable: open femoral cutdown (4.03 wRVU) once per groin, and percutaneous large-sheath closure (2.44 wRVU) once per side when a sheath of 12 Fr or larger is closed with a closure device. These are among the most commonly missed revenue items in EVAR. Only simple arteriotomy closure repair is bundled.
- Radiological supervision and interpretation is bundled into the EVAR codes, so do not separately bill intraoperative completion angiography. Diagnostic aortography performed at a prior separate session is separately reportable.
- Global period is 90 days. Post-op CT surveillance for endoleak, routine follow-up, and routine contrast studies are bundled. Endoleak embolization within the global uses the unplanned-return-to-OR modifier. Planned staged procedures (e.g., scheduled contralateral limb extension at a second session) use the staged-procedure modifier.