Can we code the following procedure with
37205
35476
36011
36145
75960-26
75978-26
75790-26 ?
Clinical history: Patient is a 62-year-old woman status post right
arm brachial artery to transposed basilic vein fistula. Patient
presents with extensive bleeding after puncture during dialysis.
There is aneurysmal dilatation of the vessel at this site of
bleeding suggesting pseudo-aneurysmal bleed.
Procedure:
The patient was placed supine on the angiography table.
The left upper arm was prepped
and draped in the usual sterile fashion. There was continuous
physiologic monitoring of the patient throughout the procedure.
After local anesthesia was obtained the basilic vein was was
entered several centimeters after the arterial anastomosis site
with a 21-gauge micropuncture needle in antegrade fashion.
Utilizing exchange techniques a 7-French vascular sheath was
placed. Digital subtraction angiography demonstrated a focal area
of pseudoaneurysmal dilatation in the area of patient's recent
bleed. There is a second less prominent area of pseudoaneurysmal
dilatation of the basilic vein more proximal to the arterial
anastomosis site. The remainder the basilic vein was widely
patent. There was an area possible web noted in the region of the
subclavian vein. A 12 mm x 4 cm balloon was used to cross and
dilate this area. Inflation of the balloon failed to demonstrate
significant waste suggesting that area possible web was possible
artifact.
Secondary to the curve created by the transposed fistula of the
initial puncture could not be utilized for stent placement. Given
the location of the area of pseudoaneurysmal dilatation just at
the level of the elbow a second puncture site of the basilic vein
at the level of the mid shaft of the humerus was identified by
ultrasound. After local anesthesia was obtained utilizing direct
ultrasound guidance a 21-gauge needle was advanced into the
basilic vein at the level of the mid shaft of the humerus in a
retrograde fashion. Utilizing exchange techniques a 7-French
vascular sheath was placed. An Amplatz wire was then advanced
into the basilic vein. Attempts at advancing a 9 mm x 4 cm
fluency stent without the use of a sheath were unsuccessful. As
such a 9-French vascular sheath was eventually placed over the
wire. A 9 mm x 4 cm fluency balloon was then deployed across the
area of pseudoaneurysmal dilatation with post deployment
angioplasty to 9 mm. Follow-up fistulogram demonstrated exclusion
of the pseudoaneurysm without evidence of endo- leak. The sheaths
were subsequently removed and compression applied manually and
with the use of pursestring sutures were 2-0 Prolene sutures until
hemostasis was obtained. After 20 minutes of compression the
puncture site near the arterial anastomosis was well contained
without evidence of surrounding hematoma. The puncture site high
near the level of the mid shaft of the humerus demonstrated the
presence of the hematoma more centrally along the proximal shaft
of the humerus. This appeared stable. Additional observation for
30 minutes was performed and hematoma appeared stable. The
patient was otherwise stable. Sterile dressings were applied.
Impression:
1. Patient with focal areas pseudoaneurysmal dilatation noted of
the basilic vein just distal to the elbow joint. This was
successfully crossed with a 9 mm x 4 cm fluency stent with
exclusion of the pseudoaneurysm on follow-up angiography.
2. Status post angioplasty of the central subclavian vein with 12
mm x 4 cm balloon
37205
35476
36011
36145
75960-26
75978-26
75790-26 ?
Clinical history: Patient is a 62-year-old woman status post right
arm brachial artery to transposed basilic vein fistula. Patient
presents with extensive bleeding after puncture during dialysis.
There is aneurysmal dilatation of the vessel at this site of
bleeding suggesting pseudo-aneurysmal bleed.
Procedure:
The patient was placed supine on the angiography table.
The left upper arm was prepped
and draped in the usual sterile fashion. There was continuous
physiologic monitoring of the patient throughout the procedure.
After local anesthesia was obtained the basilic vein was was
entered several centimeters after the arterial anastomosis site
with a 21-gauge micropuncture needle in antegrade fashion.
Utilizing exchange techniques a 7-French vascular sheath was
placed. Digital subtraction angiography demonstrated a focal area
of pseudoaneurysmal dilatation in the area of patient's recent
bleed. There is a second less prominent area of pseudoaneurysmal
dilatation of the basilic vein more proximal to the arterial
anastomosis site. The remainder the basilic vein was widely
patent. There was an area possible web noted in the region of the
subclavian vein. A 12 mm x 4 cm balloon was used to cross and
dilate this area. Inflation of the balloon failed to demonstrate
significant waste suggesting that area possible web was possible
artifact.
Secondary to the curve created by the transposed fistula of the
initial puncture could not be utilized for stent placement. Given
the location of the area of pseudoaneurysmal dilatation just at
the level of the elbow a second puncture site of the basilic vein
at the level of the mid shaft of the humerus was identified by
ultrasound. After local anesthesia was obtained utilizing direct
ultrasound guidance a 21-gauge needle was advanced into the
basilic vein at the level of the mid shaft of the humerus in a
retrograde fashion. Utilizing exchange techniques a 7-French
vascular sheath was placed. An Amplatz wire was then advanced
into the basilic vein. Attempts at advancing a 9 mm x 4 cm
fluency stent without the use of a sheath were unsuccessful. As
such a 9-French vascular sheath was eventually placed over the
wire. A 9 mm x 4 cm fluency balloon was then deployed across the
area of pseudoaneurysmal dilatation with post deployment
angioplasty to 9 mm. Follow-up fistulogram demonstrated exclusion
of the pseudoaneurysm without evidence of endo- leak. The sheaths
were subsequently removed and compression applied manually and
with the use of pursestring sutures were 2-0 Prolene sutures until
hemostasis was obtained. After 20 minutes of compression the
puncture site near the arterial anastomosis was well contained
without evidence of surrounding hematoma. The puncture site high
near the level of the mid shaft of the humerus demonstrated the
presence of the hematoma more centrally along the proximal shaft
of the humerus. This appeared stable. Additional observation for
30 minutes was performed and hematoma appeared stable. The
patient was otherwise stable. Sterile dressings were applied.
Impression:
1. Patient with focal areas pseudoaneurysmal dilatation noted of
the basilic vein just distal to the elbow joint. This was
successfully crossed with a 9 mm x 4 cm fluency stent with
exclusion of the pseudoaneurysm on follow-up angiography.
2. Status post angioplasty of the central subclavian vein with 12
mm x 4 cm balloon