I am being told to bill limited ultrasound, 71010 but not sure I really agree with that. Any thoughts??? Thank you. Sue

Right upper arm AV graft angiogram, declotting of right brachial to axillary graft, 6 mm balloon angioplasty of venous anastomosis, 8 mm balloon angioplasty of native axillary vein

Indication: This is a 64-year-old male with a history of multiple failed right arm AV fistulas. He had a right upper arm brachial artery to axillary vein 6 mm Gore-Tex AV graft placed in July of 2014. He was last dialyzed on 10/17/14 without issues and then was noted to have a nonpalpable thrill the following day. He was unable to get dialyzed today due to the clotted graft. We therefore brought him in for declotting and further intervention as indicated.

Procedure details: Informed consent was obtained prior to the procedure. The patient was brought back to the IR table and placed in the supine position with his right arm out on a board. His right upper arm was prepped and draped in the usual sterile fashion. A timeout was performed. I started with ultrasound to assess the patency of the graft. There was patent triphasic flow through the right brachial artery in the distal upper arm. There is a patent arterial anastomosis with flow going into approximately the first 2 cm of the graft. Graft thereafter was completely clotted.

An area in the patent portion of the proximal graft was chosen for puncture in an antegrade fashion. 2% plain lidocaine was injected in the skin above this. The graft was accessed with a micropuncture needle using palpation. A microwire advanced easily and the sheath was advanced over that. A 15 cm J-wire was placed through the sheath and a short 6-French sheath was placed into the graft. There was no blood return initially. Angiogram showed blood refluxing back into the native arterial system and down the arm. Berenstein catheter was placed over the J-wire and the wire was then removed. 4 mg of TPA in total were instilled into the graft along the length of the upper arm. After a few minutes of dwell time an over-the-wire Fogarty catheter was placed into the axillary vein and pulled back, however it popped mid graft. This was removed and a 6 x 20 mm compliant balloon was placed in the tip of the sheath and inflated to 2 mm of mercury. This was then pushed back and forth through the graft in order to macerate the clot. An angiogram then showed near-complete clearance of all clot with flow into the subclavian vein as well as a tight stenosis of the venous anastomosis. A venogram of the right axillary, subclavian, and superior vena cava was performed showing widely patent vessels. The 6 x 20 mm balloon was then placed at the venous anastomosis and inflated. There is no waist noted. A followup angiogram showed a widely patent anastomosis with some irregularity of the axillary vein beyond it. An 8 x 20 mm compliant balloon was then inflated to nominal pressure in the segment of the axillary vein just beyond the anastomosis. Followup angiogram showed a widely patent system with no evidence of stenosis and smooth borders to the native vein wall. An angiogram of the proximal graft (toward the elbow) was then obtained showing a widely patent graft with one area in the mid graft showing a small amount of residual clot. The 6 x 20 mm balloon was placed back into the graft and blown up to contour in this section. Followup angiogram showed a smooth contour in the graft with no residual clot. A retrograde compression angiogram was then obtained of the arterial anastomosis and distal brachial artery showing no evidence of significant arterial anastomotic stenosis. A 4-0 Monocryl pursestring suture was placed in the skin and the sheath was pulled. Direct pressure was applied for approximately 15 minutes. Thereafter there was bleeding noted and a D-Stat was placed with further compression.

The patient tolerated the procedure well with no complications. There is an easily palpable pulse in the graft following the procedure. There is a 2+ radial artery palpable pulse at the wrist.

Findings: Clot within the right upper arm AV graft starting at approximately 2 cm beyond the arterial anastomosis. Following the declotting procedure, there is evidence of an approximately 50% stenosis at the venous anastomosis with irregularity in the native axillary vein just beyond the anastomosis. Following balloon angioplasty of these segments, angiogram shows a widely open venous anastomosis and venous outflow tract. Widely patent central axillary and subclavian veins. No evidence of SVC stenosis. Patent arterial anastomosis with no obvious arterial inflow disease.

Result Impression

Successful declotting of right upper arm AV graft following TPA infusion and mechanical thrombectomy as well as venous anastomotic balloon angioplasty. Irregularity of the right axillary vein beyond the venous anastomosis was successfully ballooned and appears more regular with smooth contour following angioplasty. Widely patent central veins. Widely patent arterial anastomosis. Palpable pulse within the AV graft and palpable radial pulse at procedure completion.