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.
- If rib or costal cartilage was resected for access (rare in standard EVAR), document separately.
- ICD-10: I71.43 (infrarenal AAA without rupture, most common elective EVAR indication), I71.33 (infrarenal AAA, ruptured), I72.3 (iliac artery aneurysm). I71.41/I71.42 for pararenal/juxtarenal without rupture.
Documentation & Reimbursement Considerations
- Primary service: Report Endovascular Aortic Aneurysm Repair (EVAR) as the primary service when it is the definitive operation performed.
- These are mutually exclusive standalone primary codes — select based on graft configuration.
- These are NOT revision or redo codes. There is no dedicated revision EVAR code; elective reintervention is coded with the relevant intervention code for the work performed.
- These are among the most commonly missed revenue items in EVAR. Only the arteriotomy closure repair reporting options is bundled.
- Do not separately bill for 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 requires related unplanned return-to-the-operating-room reporting (unplanned return for complication) within the global. Planned staged procedures (e.g., scheduled contralateral limb extension at a second session) use staged-or-related-procedure reporting.