Femoral-Popliteal Bypass

CPT 35556
Approach Open
Add-on / Variant CPTs
  • 35566 — Femoral-anterior tibial / posterior tibial / peroneal bypass
  • 35700 — Reoperation peripheral bypass (add-on)
Preoperative Diagnosis:

Right [left] lower extremity [critical limb ischemia / claudication / rest pain / tissue loss] — [SFA occlusion / stenosis] on imaging

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] femoral to [above-knee / below-knee] popliteal bypass with [reversed saphenous vein / in-situ saphenous vein / PTFE / Dacron]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal [/ spinal]

Indications:

The patient is a [age]-year-old [male/female] with [critical limb ischemia / disabling claudication / ABI X] secondary to [SFA occlusion / stenosis] presenting for femoral to [above-knee / below-knee] popliteal bypass. The risks, benefits, and alternatives including endovascular therapy were discussed and informed consent was obtained.

Findings:

The common femoral artery was [soft / calcified / patent]. The [above-knee / below-knee] popliteal artery was identified at the [medial above-knee / below-knee medial] approach and was [soft / mildly calcified / patent on inflow]. The [reversed / in-situ] greater saphenous vein was [adequate diameter (X mm) / used / unsuitable requiring prosthetic conduit]. Completion angiogram demonstrated a [patent graft with good runoff / no technical defects].

Description of Procedure:

The patient was positioned supine with the ipsilateral leg externally rotated and the knee slightly flexed. The groin, thigh, and knee were prepped and draped in sterile fashion.

The common femoral artery was exposed through a vertical groin incision. The CFA, SFA origin, and profunda femoris were dissected and controlled. The [above-knee / below-knee] popliteal artery was exposed through a medial [thigh / leg] incision. The popliteal artery was dissected and controlled above and below the target anastomosis site.

The greater saphenous vein was harvested [as a reversed segment / in situ]. Side branches were ligated with [clips / silk ties]. Vein diameter was measured at both ends — [X mm]. The vein was [reversed / prepared with valvulotome for in-situ technique].

Systemic heparin [100 units/kg] was administered and ACT confirmed >250 seconds. The proximal anastomosis was constructed end-to-side to the CFA with running [6-0 Prolene]. The vein graft was tunneled through the subsartorial [medial] canal to the popliteal space. The distal anastomosis was constructed end-to-side to the [above-knee / below-knee] popliteal artery with running [6-0 Prolene]. Clamps were released and the graft filled immediately. Pulses were palpable in the [foot / distal graft] following reperfusion.

Completion [duplex / angiogram] confirmed [graft patency / no stenosis / no technical defect]. Wounds were closed in layers. A [JP drain] was [placed / not placed] in the groin.

Complications:

None

Specimens:

None

Estimated Blood Loss:

[X] mL

Drains:

None / [JP drain in groin]

Disposition:

The patient tolerated the procedure well and was taken to the PACU in stable condition with palpable [doppler] distal pulses.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** lower extremity ischemia — SFA ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** femoral to *** popliteal bypass with ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***

INDICATIONS: .PTAGE-year-old .PTSEX with *** ischemia/ABI ***. SFA ***. Consent obtained.

FINDINGS: CFA ***. Popliteal artery ***. Conduit: *** vein *** mm / prosthetic. Completion imaging: patent, no defects.

PROCEDURE:
Supine, leg externally rotated. Groin and medial *** exposure. CFA, SFA, profunda controlled. *** popliteal artery dissected. GSV harvested [reversed/in-situ], *** mm diameter. Heparin *** units/kg, ACT >250. Proximal anastomosis end-to-side CFA with 6-0 Prolene. Graft tunneled subsartorius. Distal anastomosis end-to-side *** popliteal with 6-0 Prolene. Clamps released — graft filled, distal pulses palpable. Completion ***: patent.

EBL: *** mL
COMPLICATIONS: None
DISPOSITION: PACU, distal pulses ***.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Prosthetic Conduit (PTFE / Dacron)

The greater saphenous vein was inadequate [small caliber / prior harvest / varicosities]. A [6 mm / 8 mm] ringed PTFE graft was selected. The proximal and distal anastomoses were constructed as described. A [Miller] cuff was constructed at the distal anastomosis to improve patency with a prosthetic-to-popliteal anastomosis. Completion duplex confirmed patency.

Femoral-Tibial Bypass

Given occlusion of the popliteal artery, bypass was extended to the [anterior tibial / posterior tibial / peroneal] artery at the ankle [or mid-leg]. The target artery was exposed through a [medial / anterior] approach. A vein graft was required given the distal target — prosthetic conduit is contraindicated below the knee due to poor patency. The distal anastomosis was constructed end-to-side with running 7-0 Prolene.

Charting Tips
  • Document vein conduit diameter. Vein grafts <3.5 mm have significantly reduced patency. If a small-caliber vein was used, document the decision rationale. Document all conduit options considered.
  • Document distal pulse exam and ankle-brachial index after reperfusion. This is the primary outcome measure of the procedure and must be explicitly documented. Doppler signals should be used if pulses are not palpable.
  • Record heparin dose and ACT. Document whether protamine was given at closure (avoids post-operative hematoma) and the dose used. For vein bypasses, many surgeons do not reverse with protamine. Document your practice.
Billing Tips
  • Conduit type drives code: 35556 (prosthetic fem-pop, 26.08 wRVU) vs 35583 (vein graft fem-pop, 27.06 wRVU). Vein graft is higher-weighted due to harvest complexity.
  • Target vessel drives code: fem-popliteal above knee vs below knee uses the same CPT. Document popliteal level (above/below knee) for clinical completeness but it doesn't change code tier.
  • Tibial/peroneal target: 35566 (prosthetic, 31.54 wRVU) or 35585 (vein, 31.54 wRVU). These are higher-weighted than popliteal targets.
  • Popliteal-tibial bypass: 35587 (vein, 25.55 wRVU) when inflow is the popliteal artery. Document the inflow vessel precisely.
  • Vein harvest (saphenous, arm vein): bundled into bypass codes when the harvest is from the same extremity. Contralateral harvest may be separately billable with modifier -59.
  • Intraoperative angiography is separately billable when performed as a completion study. Document indication and findings separately.
  • Global period is 90 days. Post-op ABI monitoring, graft surveillance duplex, and wound care are bundled. Thrombectomy for graft occlusion within the global uses modifier -78.