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HELP CODE PLEASE: LT Arm AVG 36830 with Repair35190

kmvmw1@gmail.com

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HOW WOULD YOU CODE THIS CASE? I have 36830-LT and 35190-LT right now. Am I overlooking anything. Please HELP???


DATE OF PROCEDURE:
April 28, 2016

PREOPERATIVE DIAGNOSIS:
End-stage renal disease.

POSTOPERATIVE DIAGNOSIS:
End-stage renal disease.

PROCEDURE PERFORMED:
Left brachiocephalic fistula converted to a left upper arm arteriovenous graft.

ASSISTANT:
PA-C. The assistance of Mr. was critical in the safe and prompt completion of this case. Mr.assisted in the initial dissection and fistula creation of the brachiocephalic fistula, which was then converted to an AV graft, and he assisted with dissection of the axillary vein, as well as assisting with both anastomoses and closure of the wounds.

ANESTHESIA:
Left arm supraclavicular nerve block and conscious sedation.

ANESTHESIOLOGIST:
AR. Anesthetist was CR, CRNA.

ESTIMATED BLOOD LOSS:
200 mL.

INDICATION FOR THE PROCEDURE:
This is a 70-year-old gentleman with a history of end-stage renal disease on hemodialysis. He was initially seen in consultation in the hospital last month, at which stage he was initiated on dialysis through a right IJ PermCath that we placed for him. He followed up in our office following this and underwent vein mapping to plan for long-term dialysis access. The vein mapping showed he had very borderline caliber veins, which were just 3 mm cephalic vein in the upper arm on the left side. I discussed with him performing a native fistula for the brachiocephalic fistula and discussed risks including failure to mature amongst other things. We also discussed regarding an AV graft if the fistula does not work. He understood the information presented and elected to proceed.

COMPLICATIONS:
Patient had an iatrogenically injury to his cephalic vein on completion of the AV fistula, which was not salvageable and resulted in conversion to an AV graft.

FINDINGS:
Patient has very borderline caliber cephalic vein.

PROCEDURE IN DETAIL:
Patient was transported to the operating room, placed supine on the operating table. The patient had received a supraclavicular nerve block prior to being brought to the OR. Following this, he was given some IV sedation and monitored by the anesthesia service. His left arm was then clipped, prepped, draped in the usual sterile fashion with ChloraPrep. A time-out was performed identifying the correct patient and procedure.

I began by making a transverse incision in the patient's arm just proximal to the antecubital fossa. This was carried down through the subcutaneous tissues with cautery. The cephalic vein was identified first and was dissected circumferentially free for a short distance. I noted that the cephalic vein caliber was very small and barely 3 mm before being distended. Once we had adequately dissected out the cephalic vein, I turned my attention to dissecting out the brachial artery. The bicipital aponeurosis was opened with cautery, and a brachial artery was then dissected circumferentially free for a short distance as well. Vessel loops were placed for vascular control. At this stage, the patient was heparinized. After sufficient time was allowed for this to circulate, angled DeBakey vascular clamps were placed proximally and distally on the brachial artery. Prior to this, the cephalic vein was clamped distally with a right-angle clamp and transected with Metzenbaum scissors. The distal end was ligated with a 2-0 silk tie. The transected end was then distended with heparinized saline and was marked for orientation. Once this was done, the vein was spatulated to appropriate size. The arteriotomy was made in the brachial artery with an 11 blade scalpel and extended with Potts scissors. We then made an end-to-side anastomosis between the cephalic vein and the brachial artery with a running 6-0 Prolene suture. Just prior to completion of the anastomosis, backbleeding and flushing maneuvers were performed. The final sutures were placed and tied down. At this stage, we released the clamps and restored flow to the cephalic vein and fistula. The proximal segment of the fistula appeared to distend nicely but was pulsatile in nature and appeared to have a twist in it. We further evaluated, and the vein indeed was twisted.

At this stage, I elected to revise this anastomosis. The clamps were then replaced on the brachial artery proximally and distally for control. The anastomosis was then taken down with an 11 blade scalpel and Potts scissors. The vein was then reoriented and was again distended to confirm orientation without any twists and kinks. Once the vein was reoriented and remarked, we then performed a new anastomosis with a running 6-0 Prolene suture again. This was done again in an end-to-side fashion with a running 6-0 Prolene. Again, prior to completion of the anastomosis, backbleeding and flushing maneuvers were performed, and final sutures were placed and secured. When we released the clamps this time, the vein did appear to distend adequately with no twists or kinks noted and a palpable thrill in the fistula throughout. At this stage, we were pleased with the fistula; however, there was a sharp turn that the fistula made in the subcutaneous tissue in the proximal swing segment, which I decided to mobilize some of the soft tissue to allow the vein to sit freely in this area. As we were mobilizing this area of soft tissue, the vein developed an iatrogenically tear in the proximal segment. We applied a bulldog clamp proximally on the cephalic vein to control bleeding through this area while we tried to repair this with interrupted 7-0 Prolene sutures. Unfortunately, the tear appeared to be greater than 50 percent in diameter of this very small vein, and as we tried to repair it, there was significant narrowing and near occlusion of the vein with the repaired sutures. At this stage, I transected the vein to see if we could spatulate the 2 ends and mobilize some more vein to bring it together; however, given the small size of the vein and the tension on it, I did not feel this was going to be a successful outcome in terms of long-term patency of this fistula. I did not feel that spatulating and splicing the vein back together would be a good outcome. On his vein mapping, he had no other appropriate venous options for a native fistula.

At this stage, then I elected to proceed to placing an AV graft in the upper arm. I then made an incision in the patient's medial upper arm in the axillary area with a 15 blade scalpel. This was carried down through the subcutaneous tissues using cautery. The brachial artery and the brachial vein in this area were identified and were dissected circumferentially free for the brachial vein. The vein was controlled with vessel loops proximally and distally, and side branches were also controlled with vessel loops. At this stage then, I used a 4 mm x 7 mm tapered Propaten graft with standard wall thickness and tunneled this with a Kelly-Wick tunneler from the proximal arm incision down to the arterial incision distally in the arm. Once the graft was in place, we distended the graft with heparinized saline and noted that it flowed well without any resistance or obstruction. We then turned our attention to bevelling the 4 mm segment of the graft to match the arteriotomy size, and we performed an end-to-side anastomosis between the graft and the brachial artery with a running 6-0 Prolene suture. Once this was completed, the vascular clamps off the brachial artery were released, restoring flow through the AV graft and down the patient's arm. The graft had good pulsatile flow throughout. We then placed a clamp proximally on the AV graft for control. At this stage, I then tightened up the vessel loops on the brachial vein proximately in the upper arm. A venotomy was then made with an 11 blade scalpel and extended with Potts scissors. The 7 mm end of the graft was then spatulated to match the appropriate size of the venotomy. An end-to-side anastomosis between the graft and the axillary vein was then performed with 6-0 Prolene suture in a running continuous fashion here. Just prior to completion of the anastomosis, the graft was then flushed forward, and backbleeding maneuvers were performed to the brachial vein as well. We then placed the final sutures and tied these down to secure the anastomosis. Clamps were then released off the AV graft and the brachial vein to restore flow through the AV graft. There was a good palpable thrill through the AV graft.

Suture lines were inspected for hemostasis. Once hemostasis was assured, a partial dose of protamine was given to reverse the heparin. Both incisions were then closed in layers with 3-0 Vicryl suture for the deeper fascial layers followed by 4-0 Monocryl in a running subcuticular fashion for the skin. Dressings were applied. The patient's sedation was lightened. He was then transferred to his hospital bed and to PACU in a stable condition.
 
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