Carotid Endarterectomy

CPT 35301
Approach Open
Add-on / Variant CPTs
  • 35390 — Reoperation carotid, thyrothyroid, vertebral (add-on)
  • 93882 — Duplex scan carotid/vertebral (intraoperative if used)
Preoperative Diagnosis:

[Symptomatic / asymptomatic] right [left] internal carotid artery stenosis — [X]% by duplex ultrasound / CTA

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] carotid endarterectomy with [primary closure / patch angioplasty]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal [/ cervical block with MAC]

Indications:

The patient is a [age]-year-old [male/female] with [symptomatic / asymptomatic] [X]% right [left] internal carotid artery stenosis presenting for carotid endarterectomy. [Symptoms: TIA / amaurosis fugax / minor stroke on (date).] The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The common, internal, and external carotid arteries were dissected and controlled. The plaque extended from the [distal CCA] to [X cm above the carotid bulb in the ICA]. The plaque was [fibrocalcific / soft / ulcerated]. The ICA backpressure [stump pressure] was [X] mmHg. [A shunt was / was not] placed. The endarterectomy plane was developed cleanly. The endpoint was [tacked with sutures / feathered].

Description of Procedure:

The patient was positioned supine with the neck extended and head rotated to the contralateral side. A longitudinal incision was made along the anterior border of the sternocleidomastoid muscle over the carotid bifurcation. The platysma was divided. The common facial vein was ligated and divided. The carotid sheath was opened and the common carotid artery (CCA), internal carotid artery (ICA), and external carotid artery (ECA) were dissected and encircled with vessel loops. The vagus nerve and hypoglossal nerve were identified and protected.

Systemic heparin [80 units/kg] was administered and ACT confirmed >250 seconds. The ICA, ECA, and CCA were clamped sequentially. [ICA stump pressure was measured at X mmHg.] [A Pruitt-Inahara shunt was placed from CCA to distal ICA.] An arteriotomy was made in the CCA extending into the ICA. The atherosclerotic plaque was elevated in the endarterectomy plane and removed en bloc with the ECA plaque eversion. The distal ICA endpoint was [clean / tacked with 6-0 Prolene sutures].

The arteriotomy was closed with running [6-0 Prolene / patch angioplasty — bovine pericardium / Dacron / vein]. Clamps were released in sequence. [Shunt was removed prior to closure.] Hemostasis was confirmed. Duplex ultrasound [or completion arteriogram] confirmed [no flap / no stenosis / normal flow].

The wound was irrigated and closed in layers. A [JP / no] drain was placed.

Complications:

None

Specimens:

Carotid endarterectomy plaque sent to pathology

Estimated Blood Loss:

[X] mL

Drains:

None / [JP drain in wound]

Disposition:

The patient tolerated the procedure well and was taken to the PACU / neuro ICU in stable condition with neurologic status intact.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** carotid stenosis — ***%
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** carotid endarterectomy with ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***

INDICATIONS: .PTAGE-year-old .PTSEX with ***% *** ICA stenosis. Symptoms: ***. Consent obtained.

FINDINGS: Plaque from *** to ***. Character: ***. Stump pressure *** mmHg. Shunt: ***. Endpoint: ***.

PROCEDURE:
Supine, neck extended, head rotated. SCM border incision. Facial vein ligated. CCA/ICA/ECA dissected, vessel loops placed. Vagus and hypoglossal nerves protected. Heparin *** units/kg, ACT >250. Sequential clamping. [Shunt placed.] Arteriotomy CCA→ICA. Plaque removed en bloc. Endpoint ***. Arteriotomy closed with *** [patch]. Clamps released. Completion duplex: ***.

COMPLICATIONS: None
EBL: ***
DRAINS: ***
DISPOSITION: To PACU/neuro ICU, neurologic status intact.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Patch Angioplasty Closure

Given [small ICA diameter / redo procedure / prior radiation], a patch angioplasty was performed using [bovine pericardium / Dacron / saphenous vein]. The patch was tailored and sutured with running 6-0 Prolene. The patch was inspected before final closure — no technical defects. Completion duplex confirmed no stenosis.

Eversion Endarterectomy

Eversion endarterectomy technique was used. The ICA was transected at the carotid bulb. The ICA was everted and the plaque removed by eversion. The ICA was reimplanted at the bulb with running 6-0 Prolene. No shunt was required. Completion imaging confirmed no stenosis or intimal flap.

Charting Tips
  • Document neurologic baseline at the start of the operative note and neuro status at the end. Stroke is the most feared complication, and documenting an intact exam on leaving the OR is critical. Also document the hypoglossal and vagus nerve identification and protection.
  • Record ICA stump pressure if measured. Stump pressure >50 mmHg generally supports proceeding without shunt. Document the shunt decision rationale explicitly: stump pressure, EEG/SSEP changes, or surgeon preference.
  • Document the distal endpoint status. A retained intimal flap is a leading cause of perioperative stroke/TIA after CEA. Explicitly state that the endpoint was clean, feathered, or tacked with sutures.
Billing Tips
  • 35301 (carotid endarterectomy, 20.63 wRVU) covers standard CEA; 35302 (with patch angioplasty, 20.82 wRVU) when a patch (vein, bovine, synthetic) is used for arteriotomy closure. Document patch use.
  • Reoperation CEA (35390, 3.11 wRVU add-on) is billed in addition to 35301/35302 when prior CEA or carotid surgery was performed on the same side. Document history of prior operation.
  • Shunt placement during CEA is bundled into 35301/35302. Do not bill separately for intraluminal shunt.
  • Intraoperative completion duplex or angiography: separately billable with modifier -59 by the operating surgeon if personally performed; document in the operative note.
  • Global period is 90 days. Post-op neurologic monitoring, carotid duplex surveillance within 90 days, and wound care are bundled. TIA or stroke post-op evaluation is bundled unless requiring a separate procedure.
  • Contralateral CEA cannot be performed within the global period of the first without modifier -79 (unrelated procedure). Document clinical indication for staged bilateral CEA.
  • Document symptomatic vs asymptomatic status, degree of stenosis (NASCET criteria), contralateral disease, shunt used (yes/no, indication), patch material, and neurological status at end of case. All affect medical necessity and quality reporting.