35876

Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or venous graft

Current Procedural Terminology (CPT) code 35876 describes an open surgical procedure to remove a blood clot (thrombus) from an existing arterial or venous bypass graft (excluding hemodialysis grafts or fistulas) combined with a surgical revision of the graft. This complex procedure is typically indicated when a patient presents with graft thrombosis, often manifesting as acute limb ischemia, severe claudication, or rest pain, accompanied by an underlying structural abnormality or lesion within the graft or at an anastomosis that precipitated the occlusion. Unlike a simple thrombectomy, which merely removes the occluding clot, CPT code 35876 involves fundamentally repairing or modifying the graft to ensure long-term patency and prevent recurrent thrombosis. During the procedure, the patient is placed under general or regional anesthesia. The vascular surgeon makes an incision over the site of the previously placed graft, usually at the proximal or distal anastomosis where the thrombosis or stenosis is suspected. Proximal and distal vascular control is obtained using vessel loops or vascular clamps. A transverse or longitudinal incision (graftotomy or arteriotomy) is made. The surgeon then utilizes embolectomy catheters (such as a Fogarty balloon catheter), passing them proximally and distally through the graft and adjacent native vessels to carefully extract the thrombotic material. Once the clot is thoroughly removed and adequate inflow and outflow are established—often confirmed via intraoperative completion angiography or duplex ultrasonography—the surgeon addresses the underlying structural defect. The 'revision' component of the procedure may involve excising a stenotic segment of the graft, performing a patch angioplasty (using autologous vein or synthetic material) to widen a narrowed anastomosis, or placing a short interposition jump graft to bypass an unsalvageable section. This critical step sets CPT 35876 apart from CPT 35875 (thrombectomy only). Following the revision, the arteriotomy is securely closed. The surgeon verifies the restoration of strong pulses and adequate distal perfusion before meticulously closing the surgical wound in layers. Post-operative care typically involves rigorous monitoring of the patient's distal pulses, hemodynamics, and the initiation of appropriate antithrombotic or anticoagulant therapy to preserve the revised graft's patency.

Clinical Indications

  • Acute limb ischemia secondary to thrombosis of a peripheral arterial bypass graft.
  • Sudden recurrence of severe claudication or rest pain in a patient with a previously functioning arterial bypass graft.
  • Absent distal pulses with imaging (duplex ultrasound or computed tomography angiography) confirming graft thrombosis and an underlying structural defect (e.g., anastomotic stricture or intimal hyperplasia).
  • Failure of a previous simple thrombectomy necessitating concurrent graft revision to maintain patency.
  • Graft thrombosis associated with an outflow stenosis that requires patch angioplasty or interposition grafting to restore continuous flow.

Procedure Steps

  1. Administer general, regional, or local anesthesia with sedation, and prep and drape the patient in a standard sterile surgical fashion.
  2. Create a surgical incision over the affected graft, typically targeting the proximal or distal anastomosis where the structural defect or primary thrombus is located.
  3. Dissect carefully to expose the graft and native vessels, and achieve proximal and distal vascular control using vessel loops or atraumatic vascular clamps.
  4. Perform an arteriotomy or graftotomy to access the lumen of the occluded graft.
  5. Insert a Fogarty embolectomy balloon catheter, advancing it proximally and distally, then inflate the balloon and carefully withdraw it to extract the thrombus.
  6. Flush the vessels with heparinized saline to clear any residual microscopic debris and ensure robust inflow and back-bleeding.
  7. Execute the graft revision, which may include excising a diseased/stenotic segment of the graft or native vessel, performing a patch angioplasty, or constructing a localized interposition jump graft.
  8. Perform completion angiography or duplex ultrasonography to confirm complete clot removal, successful structural revision, and restoration of normal hemodynamics.
  9. Close the arteriotomy or secure the newly revised graft anastomoses using fine non-absorbable sutures.
  10. Achieve strict hemostasis, verify the return of distal pulses, and close the wound in multiple anatomical layers.

Coding Guidelines

  • Do not report CPT 35876 in conjunction with CPT 35875 (Thrombectomy of arterial or venous graft without revision) for the same graft; 35876 intrinsically includes the thrombectomy.
  • Do not use CPT 35876 for the thrombectomy or revision of hemodialysis grafts or arteriovenous fistulas; instead, refer to CPT codes 36831, 36832, or 36833.
  • If multiple entirely separate grafts are thrombectomized and revised, modifier 59 (Distinct Procedural Service) or X-modifiers may be appropriately appended.
  • Use appropriate laterality modifiers (-RT for right side, -LT for left side) to indicate the specific extremity operated on.
  • Intraoperative completion angiography is typically bundled into the primary vascular procedure unless specifically performed for a distinctly separate diagnostic purpose, requiring modifier 59.

Associated ICD-10 Codes