CPT® Code 35490

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1. Indications

The procedure described by CPT® Code 35490 is indicated for patients who present with occlusions or significant stenosis in the renal or other visceral arteries. These conditions may lead to reduced blood flow, resulting in symptoms such as hypertension, renal insufficiency, or abdominal pain. The primary indications for performing a transluminal peripheral atherectomy include:

• Renal Artery Stenosis - A narrowing of the renal artery that can lead to hypertension and kidney dysfunction.
• Visceral Artery Occlusion - Blockages in arteries supplying blood to the abdominal organs, which can cause ischemia and related symptoms.
• Peripheral Artery Disease - A condition characterized by narrowed arteries reducing blood flow to the limbs, which may also affect visceral arteries.

2. Procedure

The procedure for CPT® Code 35490 involves several critical steps to ensure effective plaque removal from the renal or visceral arteries. The steps are as follows:

• Step 1: Preparation and Access - The physician begins by preparing the skin over the access artery, typically one of the femoral arteries. This preparation includes cleaning the area to reduce the risk of infection. A needle is then used to puncture the artery, and a sheath is placed to facilitate access to the vascular system.
• Step 2: Guidewire Insertion - After establishing access, a guidewire is inserted through the sheath and advanced into the occluded renal or visceral artery. This guidewire serves as a pathway for subsequent devices used in the procedure.
• Step 3: Atherectomy Catheter Advancement - The atherectomy catheter is then advanced over the guidewire. Once in position, the guidewire is withdrawn, allowing the atherectomy device to operate directly within the artery.
• Step 4: Plaque Removal - The atherectomy device utilizes a specialized balloon catheter equipped with a cutting piston. This piston is advanced through a window on the catheter, effectively shaving plaque from the arterial wall. The shaved plaque is collected in the nose of the atherectomy device.
• Step 5: Multiple Passes - The physician may perform several passes with the atherectomy device to ensure thorough removal of plaque and achieve optimal results.
• Step 6: Angiography - After the atherectomy, the device is exchanged for a guidewire, and an angiography catheter is advanced over the guidewire. The guidewire is then withdrawn, and contrast material is injected to perform a completion angiography. This imaging step is crucial to confirm that the renal or visceral artery is patent and that blood flow has been restored.
• Step 7: Post-Procedure Care - Following the completion angiography, the angiography catheter is withdrawn. The physician applies pressure to the arterial puncture site to control any bleeding and subsequently places a pressure dressing to secure the site and promote healing.

3. Post-Procedure

After the completion of the procedure, patients are monitored for any complications, particularly at the puncture site, where bleeding may occur. The application of pressure and a dressing helps to minimize this risk. Patients may be advised to rest and avoid strenuous activities for a specified period to facilitate recovery. Follow-up imaging may be necessary to ensure the continued patency of the treated artery and to monitor for any potential re-occlusion. The physician will provide specific post-procedure instructions tailored to the individual patient's needs and condition.