Question regarding Brachial Artery antegrade access RT arm angiogram.
I am not sure what code to use for Antegrade. CPT COde 36120 is for retrograde.
Any help would be appreciated. Report note below minus the CVC replacement.
PROCEDURES PERFORMED
1. Removal of PermCath, placement of new tunneled hemodialysis catheter
through a new site.
2. Selective antegrade right brachial arteriogram.
3. Conscious sedation for 45 minutes.
The patient has a complex history. He had a fistula of the left
arm, which was ligated about 3 months ago. This was done because he is
developing rest pain and ulceration of the fingers of the left hand. He
had an arteriogram at that time on both sides. This showed extensive
calcifications and small and large vessel occlusions on both upper
extremities. I have not seen him for 3 months. He came back today
because of the catheter problem. He pointed out to me, that his right
third finger is excruciatingly painful. It is extensively ulcerated now.
He had had a stellate ganglion block done on the right side, which
helped for a period of time, but he never came back to see me. That was
3 months ago. Clearly that has now failed. I decided to restudy the
right hand based upon this change in his status.
CVC replacement.......
Xylocaine was infiltrated over the brachial artery pulse just proximal
to the volar crease. The artery was accessed with a mini-stick needle. A
guidewire was passed. Over this, a 4-French micropuncture sheath was
placed.
Selective images were obtained of the right arm from the upper arm to
the fingers. Multiple views were done. The hand was rotated into several
different directions. At the conclusion of the procedure, the catheter
was removed. Pressure was held for 20 minutes. There was no bleeding and
no hematoma. The patient was taken back to the outpatient department in
good condition.
The brachial artery is widely patent and generally
nondiseased. However, distal to the volar crease, beginning at the
trifurcation, there are dense and circumferential calcifications of all
3 of the forearm vessels. The radial artery is the better vessel. It too
was a severely calcified, however. The radial artery has good diameter
until it reaches the area just proximal to the wrist at which point it
occludes. There is no reconstitution to any segment of the radial artery
in the hand. The interosseous artery is tortuous and calcified and stops
in the proximal forearm. The ulnar artery is severely and diffusely
diseased and small. It is heavily calcified. There is one segment where
it looks to be occluded for about 2 cm. I had to do multiple views to
try to sort this out because the interosseous artery was in the same
area. However, the ulnar artery reconstitutes at the mid portion of the
wrist and extends into the hand. There was good filling of a digital
artery that actually extends to the middle finger, which is the site of
the problem.
On the basis of this, I think that the ulnar artery is a reasonable
target vessel for a bypass. The patient really has nothing to lose with
this. He is clearly going to face amputation of the middle finger if
this is not accomplished. Furthermore, I think there is a high
probability that the amputation would not heal. I discussed the matter
with the patient at length, about an hour after the procedure, so he was
completely awake. I explained to him the option of doing a bypass,
likely taking a vein graft from the leg
I am not sure what code to use for Antegrade. CPT COde 36120 is for retrograde.
Any help would be appreciated. Report note below minus the CVC replacement.
PROCEDURES PERFORMED
1. Removal of PermCath, placement of new tunneled hemodialysis catheter
through a new site.
2. Selective antegrade right brachial arteriogram.
3. Conscious sedation for 45 minutes.
The patient has a complex history. He had a fistula of the left
arm, which was ligated about 3 months ago. This was done because he is
developing rest pain and ulceration of the fingers of the left hand. He
had an arteriogram at that time on both sides. This showed extensive
calcifications and small and large vessel occlusions on both upper
extremities. I have not seen him for 3 months. He came back today
because of the catheter problem. He pointed out to me, that his right
third finger is excruciatingly painful. It is extensively ulcerated now.
He had had a stellate ganglion block done on the right side, which
helped for a period of time, but he never came back to see me. That was
3 months ago. Clearly that has now failed. I decided to restudy the
right hand based upon this change in his status.
CVC replacement.......
Xylocaine was infiltrated over the brachial artery pulse just proximal
to the volar crease. The artery was accessed with a mini-stick needle. A
guidewire was passed. Over this, a 4-French micropuncture sheath was
placed.
Selective images were obtained of the right arm from the upper arm to
the fingers. Multiple views were done. The hand was rotated into several
different directions. At the conclusion of the procedure, the catheter
was removed. Pressure was held for 20 minutes. There was no bleeding and
no hematoma. The patient was taken back to the outpatient department in
good condition.
The brachial artery is widely patent and generally
nondiseased. However, distal to the volar crease, beginning at the
trifurcation, there are dense and circumferential calcifications of all
3 of the forearm vessels. The radial artery is the better vessel. It too
was a severely calcified, however. The radial artery has good diameter
until it reaches the area just proximal to the wrist at which point it
occludes. There is no reconstitution to any segment of the radial artery
in the hand. The interosseous artery is tortuous and calcified and stops
in the proximal forearm. The ulnar artery is severely and diffusely
diseased and small. It is heavily calcified. There is one segment where
it looks to be occluded for about 2 cm. I had to do multiple views to
try to sort this out because the interosseous artery was in the same
area. However, the ulnar artery reconstitutes at the mid portion of the
wrist and extends into the hand. There was good filling of a digital
artery that actually extends to the middle finger, which is the site of
the problem.
On the basis of this, I think that the ulnar artery is a reasonable
target vessel for a bypass. The patient really has nothing to lose with
this. He is clearly going to face amputation of the middle finger if
this is not accomplished. Furthermore, I think there is a high
probability that the amputation would not heal. I discussed the matter
with the patient at length, about an hour after the procedure, so he was
completely awake. I explained to him the option of doing a bypass,
likely taking a vein graft from the leg