Failing right ateriovenous fistula with right arm swelling

Stephanie Hunt

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Would 36821 be the appropriate CPT code for each arm?

Thank you in advance!

1. Failing right arteriovenous fistula with right arm swelling.
2. End stage renal disease.

1. Left radial Cimino arteriovenous (AV) fistula.
2. Ligation of branch of left radial Cimino arteriovenous (AV) fistula.
3. Access to fistula, right arm, with fistulogram (distinct).
4. Ligation right Cimino fistula (distinct).
5. Left cephalic, subclavian, and brachiocephalic venography.

The cephalic vein was occluded in the distal upper arm on the right and the basilic vein had a long, severe stenosis in the mid to proximal upper arm. The right fistula was not felt to be salvageable. Venography on the left side showed no central stenosis despite pacemaker wires.

After satisfactory induction of general anesthesia, the patient was sterilely prepped and draped. An IV placed in the left cephalic vein at the antecubital fossa was used for a single contrast central venogram going from the cephalic to the subclavian. Brachiocephalic and superior vena cava showing no stenosis despite the pacemaker wires. On that basis, I then went to the right arm, which was sterilely prepped and draped. Access to the fistula was made after local anesthesia with the micropuncture set through a 4 French sheath over the micro-wire. A fistulogram was shot showing the fistula to be patent, tortuous, and very enlarged in the forearm, but the cephalic vein cutoff just proximal to the antecubital fossa. It drained via collaterals into the basilic, but the basilic vein had a significant stenosis in the mid-proximal third junction of the humerus and then, no central stenosis was noted on that side as well. After reviewing the films carefully, I felt there was no chance to salvage this fistula and, knowing that the fistula could be placed on the other side, I then removed the sheath, secured it with a 4-0 Monocryl suture. Then, after additional local anesthesia, made a short, transverse incision over the proximal fistula, dissected down to and around it completely, and it was doubly ligated with double 3-0 silk ties, but not divided. The incision was hemostased and closed with running 4-0 Monocryl in layers and a Steri-Strip was placed.

I then went to the patient's left arm, which was then prepped and, after local anesthesia between the cephalic vein and radial artery, the fistula was dissected free. The vein was clamped distally, divided, ligated, mobilized to reach the artery. The artery was dissected free, clamped proximally and distally, after 2500 units of heparin were given. Then, the vein was mobilized, trimmed to length, and spatulated. The artery was clamped proximally and distally. Longitudinally, arteriotomy of 1.25 cm was made and the anastomosis was created with running 7-0 Prolene suture. Flow was established. There was a nice thrill in the fistula. There was a lateral branch that was tethering it. This was ligated proximally and distally with 3-0 silk ties and divided, allowing the vein to lay in a gentle curve from its native position to the anastomosis. The wound was hemostatic and it was closed with running 4-0 Monocryl in layers. Steri-Strips were placed. The right arm was then wrapped from palm to proximal forearm with Kerlix and Coban to compress blood out of the enlarged fistula to reduce clot burden in it. The patient was then allowed to wake up, taken to the recovery room in stable condition, having tolerated the procedure well. Sponge, needle, and instrument counts reported as correct x2.


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Take a look at 37607--ligation or banding of angioaccess AVF--for the right arm, and use 36821 for the left arm. I would consider the ligation of the tethering vein on the left to be a component of the fistula formation and therefore not separately billable. You could try a mod 22 for the additional work though..
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