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Thread: Stent placement - Clinical history: Patient is a 62-year-old

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    Default Stent placement - Clinical history: Patient is a 62-year-old

    AAPC: Back to School
    Can we code the following procedure with

    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.

    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

    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.
    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
    Last edited by ank3t; 10-07-2016 at 07:31 AM.
    Prabha CPC

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