NancyZ76
Contributor
Good Morning,
Can anyone please help me with this Op Note, I don't do Vascular all that often and I need help!! My head is spinning! I have been googling and Im confused. I come up with 36903 and 36908
POSTOPERATIVE DIAGNOSES:
End-stage renal disease, dialysis, poorly-functioning left arteriovenous
fistula.
PROCEDURES:
1. Percutaneous left arteriovenous fistula access.
2. Fistulogram of left arm arteriovenous fistula.
3. Angioplasty of left axillary vein.
4. Angioplasty of left subclavian vein.
5. Placement of stents of left axillary vein.
INDICATIONS FOR PROCEDURE:
The patient is a 53-year-old woman with a history of renal failure and is
being dialyzed via a left arm arteriovenous fistula. She is having problems
with the fistula and presents now for surgery. During surgery, the patient
was found to have a tight stenosis in the axillary vein as well as a tight
stenosis in the more proximal portion of the left subclavian vein, both of
these were angioplastied and the left axillary stenosis was stented.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed in a supine position.
Anesthesia was given and the arm was prepped and draped in a sterile manner.
1% lidocaine was used to infiltrate the surgical area. Percutaneously, a 4-
French micropuncture was used to access the fistula. A guidewire was inserted
and the micropuncture catheter was switched over to a 6-French introducer. A
fistulogram was performed of the left arm. The fistulogram showed that the
patient has a previously-placed stent in the axillary vein. However, beyond
the stent, the patient has a very tight stenosis that was difficult to get
through with a Bentson wire. Over the Bentson wire, an angled glide catheter
was inserted and with the manipulation of the catheter, a wire was able to
cross this area. The catheter was then inserted beyond this area and at this
point, a 2nd fistulogram was performed of the subclavian vein. The subclavian
vein fistulogram showed a tight stenosis at the mid subclavian vein. Over the
guidewire, an 8 mm balloon was inserted and guided across the stenosis.
Angioplasty of the left subclavian vein was performed, this was done at 18
atmosphere for 1 minute and repeated twice. A second fistulogram was
performed that showed the subclavian stenosis to improve dramatically and a
decision was made for no further treatment of this subclavian vein stenosis.
The catheter was then pulled back and a Bentson wire was then replaced and the
8 mm balloon was then inserted to the area of stenosis on the axillary vein
just distal to the previous stents. Angioplasty was then performed of this
area again at 18 atmosphere for 1 minute and repeated twice. A repeat
angiogram showed that the stenosis was still significant and has not improved.
A decision was made to place a stent in the axillary vein. An 8 mm stent was
inserted and guided across the stenosis and the stent was deployed under
fluoroscopy. Once the stent was deployed, a repeat angiogram was performed
showing excellent results. The introducer was removed and the puncture site
was sewn up using 4-0 Monocryl. Dressings were placed and the patient was
then transferred to the recovery room stable. No complication was seen.
Estimated blood loss was minimal.
Can anyone please help me with this Op Note, I don't do Vascular all that often and I need help!! My head is spinning! I have been googling and Im confused. I come up with 36903 and 36908
POSTOPERATIVE DIAGNOSES:
End-stage renal disease, dialysis, poorly-functioning left arteriovenous
fistula.
PROCEDURES:
1. Percutaneous left arteriovenous fistula access.
2. Fistulogram of left arm arteriovenous fistula.
3. Angioplasty of left axillary vein.
4. Angioplasty of left subclavian vein.
5. Placement of stents of left axillary vein.
INDICATIONS FOR PROCEDURE:
The patient is a 53-year-old woman with a history of renal failure and is
being dialyzed via a left arm arteriovenous fistula. She is having problems
with the fistula and presents now for surgery. During surgery, the patient
was found to have a tight stenosis in the axillary vein as well as a tight
stenosis in the more proximal portion of the left subclavian vein, both of
these were angioplastied and the left axillary stenosis was stented.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed in a supine position.
Anesthesia was given and the arm was prepped and draped in a sterile manner.
1% lidocaine was used to infiltrate the surgical area. Percutaneously, a 4-
French micropuncture was used to access the fistula. A guidewire was inserted
and the micropuncture catheter was switched over to a 6-French introducer. A
fistulogram was performed of the left arm. The fistulogram showed that the
patient has a previously-placed stent in the axillary vein. However, beyond
the stent, the patient has a very tight stenosis that was difficult to get
through with a Bentson wire. Over the Bentson wire, an angled glide catheter
was inserted and with the manipulation of the catheter, a wire was able to
cross this area. The catheter was then inserted beyond this area and at this
point, a 2nd fistulogram was performed of the subclavian vein. The subclavian
vein fistulogram showed a tight stenosis at the mid subclavian vein. Over the
guidewire, an 8 mm balloon was inserted and guided across the stenosis.
Angioplasty of the left subclavian vein was performed, this was done at 18
atmosphere for 1 minute and repeated twice. A second fistulogram was
performed that showed the subclavian stenosis to improve dramatically and a
decision was made for no further treatment of this subclavian vein stenosis.
The catheter was then pulled back and a Bentson wire was then replaced and the
8 mm balloon was then inserted to the area of stenosis on the axillary vein
just distal to the previous stents. Angioplasty was then performed of this
area again at 18 atmosphere for 1 minute and repeated twice. A repeat
angiogram showed that the stenosis was still significant and has not improved.
A decision was made to place a stent in the axillary vein. An 8 mm stent was
inserted and guided across the stenosis and the stent was deployed under
fluoroscopy. Once the stent was deployed, a repeat angiogram was performed
showing excellent results. The introducer was removed and the puncture site
was sewn up using 4-0 Monocryl. Dressings were placed and the patient was
then transferred to the recovery room stable. No complication was seen.
Estimated blood loss was minimal.