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Is there anyone who can help me with the following? I have 36903 and 76937, but I am not sure if this is correct. Any help would be appreciated!
History: End-stage renal disease, on hemodialysis through the RIGHT upper extremity brachial axillary AV graft. Patient had the prolonged bleeding after dialysis. Patient presents IR for the ultrasound and fluoroscopy-guided fistulogram of the RIGHT
upper extremity AV graft, angioplasty and stenting with conscious sedation.
Comparison: IR dialysis fistulogram on 01/09/2024
Medications:
1. Versed 2 mg IV
2. Fentanyl 75 mcg IV
3. Lidocaine 2% for local anesthesia 2 ml
4. Heparin 3000 units IV
Upper extremity IV was used. Patient underwent continuous physiologic monitoring throughout the procedure. Conscious sedation was administered and monitored by me with total of 120minutes monitoring time.
Contrast Data: 50 mL Isovue-300 endovascular
Fluoroscopy Time: 27 Minutes
Total Skin Dosage: 100 mGy
Complications: None
Specimens: None
Estimated blood loss: Minimal
Description: Written informed consent was obtained from patient. Maximum sterile barrier was used. The patient was placed Supine. Preliminary examination demonstrated pulse with no thrill through the AVG. Preliminary ultrasound demonstrated patency of
the arterial anastomosis and AV graft, and stenosis at the venous anastomosis
Using real-time ultrasound for guidance and documentation, micropuncture needle was used to access the AV graft just above the level of the arterial anastomosis and directed centrally. Micropuncture wire was advanced through the needle into the AV graft.
Needle was removed and replaced with a micropuncture sheath. Contrast was injected through the micropuncture sheath for a fistulogram, demonstrating severe stenosis at the venous anastomosis with the multiple dilated collateral veins originating distal
to the stenosis, complete occlusion at the junction of the RIGHT subclavian vein to innominate vein with the multiple dilated collateral veins originating distal to the occlusion. The retrograde fistulogram was performed with manual compression on the AV
graft, demonstrating wide patency of the arterial anastomosis, inflow and outflow arteries.
The micropuncture sheath was removed and replaced with a 6 French sheath. Kumpe catheter in conjunction with glide advantage wire, and then Roadrunner wire, was placed through the graft, venous anastomosis, RIGHT axillary vein, and subclavian vein. The
attempt to advance the Roadrunner wire and the guidewire through the occlusion at the distal subclavian vein was unsuccessful. The catheter was exchanged for a 90 degree navicross catheter and guidewire was exchanged for a 0.018 inches Zilient wire. The
guidewire was navigated through the occlusion into the superior vena cava, RIGHT atrium and the vena cava. The catheter was advanced over the guidewire into the inferior vena cava. A pullback venogram was performed to confirm location, demonstrating
occlusion at the junction of the RIGHT subclavian vein to the innominate vein.
And then, angioplasty was performed at the venous anastomosis and the distal RIGHT subclavian vein using 7 mm and 8 mm balloons (Conquest). Post angioplasty venogram was performed, demonstrating residual moderate stenosis at the venous anastomosis and
the severe stenosis at the distal RIGHT subclavian vein. Angioplasty was performed using a 10 mm balloon at the distal LEFT subclavian vein. Post angioplasty venogram was performed, demonstrating residual severe stenosis at the distal RIGHT subclavian
vein.
Subsequently, a 7 mm x 60 mm Covera stent was deployed at the venous anastomosis fluoroscopy guidance. After balloon dilation, venogram was performed demonstrating wide patency of the venous anastomosis with no dilated collateral veins.
And then, a 12 mm x 80 mm Venova stent was deployed at the junction of the RIGHT subclavian vein and innominate vein. After balloon dilation, venogram was performed, demonstrating wide patency of the RIGHT subclavian vein and innominate vein with no
dilated collateral veins.
The final fistulogram through the sheath was performed demonstrating wide patency of the AV graft, arterial and venous anastomoses, RIGHT axillary vein, subclavian, innominate vein with no significant dilated collateral veins.
Wires and sheath were removed and the patient. Hemostasis was achieved with purse string stitch which will be removed in 2 hours. Band-Aid was applied to the skin site. A pulsatile thrill was present in the graft postprocedure. Results were discussed
with the patient and patient's family. The patient tolerated the procedure well and left procedure suite for return to recovery room in good condition.
Multiple hardcopy ultrasound and fluoroscopic images were obtained throughout the procedure and permanently stored in PACS system.
Impression:
1. Fistulogram of RIGHT upper arm AV graft demonstrated severe stenosis at the venous anastomosis with the multiple dilated collateral veins originating distal to the stenosis, and complete occlusion at the junction of the RIGHT subclavian vein to
innominate vein with the multiple dilated collateral veins originating distal to the occlusion.
2. Successful angioplasty and stenting of the venous anastomosis, and the junction of the RIGHT subclavian vein to the innominate vein.
3. Post operative fistulogram demonstrated wide patency of the AV graft, arterial and venous anastomoses, RIGHT axillary vein, subclavian, innominate vein with no significant dilated collateral veins.
History: End-stage renal disease, on hemodialysis through the RIGHT upper extremity brachial axillary AV graft. Patient had the prolonged bleeding after dialysis. Patient presents IR for the ultrasound and fluoroscopy-guided fistulogram of the RIGHT
upper extremity AV graft, angioplasty and stenting with conscious sedation.
Comparison: IR dialysis fistulogram on 01/09/2024
Medications:
1. Versed 2 mg IV
2. Fentanyl 75 mcg IV
3. Lidocaine 2% for local anesthesia 2 ml
4. Heparin 3000 units IV
Upper extremity IV was used. Patient underwent continuous physiologic monitoring throughout the procedure. Conscious sedation was administered and monitored by me with total of 120minutes monitoring time.
Contrast Data: 50 mL Isovue-300 endovascular
Fluoroscopy Time: 27 Minutes
Total Skin Dosage: 100 mGy
Complications: None
Specimens: None
Estimated blood loss: Minimal
Description: Written informed consent was obtained from patient. Maximum sterile barrier was used. The patient was placed Supine. Preliminary examination demonstrated pulse with no thrill through the AVG. Preliminary ultrasound demonstrated patency of
the arterial anastomosis and AV graft, and stenosis at the venous anastomosis
Using real-time ultrasound for guidance and documentation, micropuncture needle was used to access the AV graft just above the level of the arterial anastomosis and directed centrally. Micropuncture wire was advanced through the needle into the AV graft.
Needle was removed and replaced with a micropuncture sheath. Contrast was injected through the micropuncture sheath for a fistulogram, demonstrating severe stenosis at the venous anastomosis with the multiple dilated collateral veins originating distal
to the stenosis, complete occlusion at the junction of the RIGHT subclavian vein to innominate vein with the multiple dilated collateral veins originating distal to the occlusion. The retrograde fistulogram was performed with manual compression on the AV
graft, demonstrating wide patency of the arterial anastomosis, inflow and outflow arteries.
The micropuncture sheath was removed and replaced with a 6 French sheath. Kumpe catheter in conjunction with glide advantage wire, and then Roadrunner wire, was placed through the graft, venous anastomosis, RIGHT axillary vein, and subclavian vein. The
attempt to advance the Roadrunner wire and the guidewire through the occlusion at the distal subclavian vein was unsuccessful. The catheter was exchanged for a 90 degree navicross catheter and guidewire was exchanged for a 0.018 inches Zilient wire. The
guidewire was navigated through the occlusion into the superior vena cava, RIGHT atrium and the vena cava. The catheter was advanced over the guidewire into the inferior vena cava. A pullback venogram was performed to confirm location, demonstrating
occlusion at the junction of the RIGHT subclavian vein to the innominate vein.
And then, angioplasty was performed at the venous anastomosis and the distal RIGHT subclavian vein using 7 mm and 8 mm balloons (Conquest). Post angioplasty venogram was performed, demonstrating residual moderate stenosis at the venous anastomosis and
the severe stenosis at the distal RIGHT subclavian vein. Angioplasty was performed using a 10 mm balloon at the distal LEFT subclavian vein. Post angioplasty venogram was performed, demonstrating residual severe stenosis at the distal RIGHT subclavian
vein.
Subsequently, a 7 mm x 60 mm Covera stent was deployed at the venous anastomosis fluoroscopy guidance. After balloon dilation, venogram was performed demonstrating wide patency of the venous anastomosis with no dilated collateral veins.
And then, a 12 mm x 80 mm Venova stent was deployed at the junction of the RIGHT subclavian vein and innominate vein. After balloon dilation, venogram was performed, demonstrating wide patency of the RIGHT subclavian vein and innominate vein with no
dilated collateral veins.
The final fistulogram through the sheath was performed demonstrating wide patency of the AV graft, arterial and venous anastomoses, RIGHT axillary vein, subclavian, innominate vein with no significant dilated collateral veins.
Wires and sheath were removed and the patient. Hemostasis was achieved with purse string stitch which will be removed in 2 hours. Band-Aid was applied to the skin site. A pulsatile thrill was present in the graft postprocedure. Results were discussed
with the patient and patient's family. The patient tolerated the procedure well and left procedure suite for return to recovery room in good condition.
Multiple hardcopy ultrasound and fluoroscopic images were obtained throughout the procedure and permanently stored in PACS system.
Impression:
1. Fistulogram of RIGHT upper arm AV graft demonstrated severe stenosis at the venous anastomosis with the multiple dilated collateral veins originating distal to the stenosis, and complete occlusion at the junction of the RIGHT subclavian vein to
innominate vein with the multiple dilated collateral veins originating distal to the occlusion.
2. Successful angioplasty and stenting of the venous anastomosis, and the junction of the RIGHT subclavian vein to the innominate vein.
3. Post operative fistulogram demonstrated wide patency of the AV graft, arterial and venous anastomoses, RIGHT axillary vein, subclavian, innominate vein with no significant dilated collateral veins.