Endovascular Aortic Aneurysm Repair (EVAR)

CPT 34705
Approach Endovascular
Add-on / Variant CPTs
  • 34701 — EVAR, aorto-aortic (tube graft) endoprosthesis
  • 34812 — Open femoral artery exposure for endovascular procedure (add-on)
Preoperative Diagnosis:

Abdominal aortic aneurysm — [X] cm maximum diameter, anatomically suitable for EVAR

Postoperative Diagnosis:

Same

Procedure Performed:

Endovascular abdominal aortic aneurysm repair (EVAR) — [device: Endurant / Excluder / Zenith]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal [/ spinal / MAC with local]

Indications:

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.

Findings:

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.

Description of Procedure:

The patient was positioned supine on the angiography table. Bilateral groin cutdowns were performed through longitudinal incisions. The common femoral arteries were dissected and controlled with vessel loops. Systemic heparin [100 units/kg] was administered and ACT confirmed >250 seconds.

Access was obtained with [18-gauge] needles bilaterally and [7 Fr] sheaths placed. 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.

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]. Femoral pulses were confirmed. Wounds were closed in layers.

Complications:

None

Specimens:

None

Estimated Blood Loss:

[X] mL

Drains:

None

Disposition:

The patient tolerated the procedure well and was taken to the PACU in stable condition. Follow-up CTA at [1 month / 12 months] was scheduled per EVAR surveillance protocol.

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. Heparin *** units/kg, ACT >250. Bilateral access, stiff wires in descending thoracic aorta. *** device main body deployed *** mm below lowest renal. Contralateral limb gate cannulated, limb deployed. Ipsilateral limb to ***. Overlap ≥3 cm confirmed. Completion angio: ***. Sheaths removed. Arteriotomies repaired with 5-0 Prolene. Pulses confirmed. Wounds closed.

EBL: *** mL
COMPLICATIONS: None
DISPOSITION: To PACU, CTA follow-up scheduled.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Type II Endoleak — Embolization

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. [Percutaneous embolization was performed: the IMA was cannulated via the SMA collateral pathway and coil-embolized.] Alternatively, the type II endoleak was observed given low-flow character and will be reassessed on 1-month CTA.

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 (CTA at 1, 12, and 24 months, then annually). This establishes the surveillance protocol and is a quality metric.
Billing Tips
  • 34705 (EVAR aorto-biiliac, primary, 28.84 wRVU) is the standard code for bifurcated endograft repair of infrarenal AAA. This is the most common EVAR configuration.
  • 34703 (aorto-uniiliac, 25.86 wRVU) applies when a uniiliac device is used (e.g., with contralateral iliac occlusion and femoral-femoral bypass); 34707 (ilio-iliac, 21.72 wRVU) for isolated iliac aneurysm repair.
  • Repeat/revision EVAR: 34704 (aorto-uniiliac, 43.88 wRVU), 34706 (aorto-biiliac, 43.88 wRVU). These are higher-weighted because revision is more complex. Document prior endograft and nature of reintervention.
  • Extension limb placement at the same session: 34709 (+6.34 wRVU add-on per extension). Bill once per extension limb deployed. Delayed extension placement uses 34710/34711.
  • Femoral artery cutdown and closure are bundled; do not separately bill 35226 for femoral repair. Percutaneous access with closure device (Perclose, ProGlide) is bundled.
  • Completion angiography imaging is bundled into EVAR codes. Do not separately bill 75952 (aortic imaging) when performed as part of the same EVAR procedure.
  • Global period is 90 days. Post-op CT surveillance for endoleak, routine follow-up, and routine contrast studies are bundled. Endoleak embolization requires modifier -78 (complication) within the global.