AV Fistula - Can anyone help me with this?
Can anyone help me with this? I'm in so many different directions with this.... what can and can't be coded since some attempts were not successful?
1. Left upper extremity AV fistulogram with balloon angioplasty
2. Central venogram via right internal jugular access
3. ultrasound guidance access in the central venous system
Patient was brought in and placed on table in supine position. The left upper extremity was prepped and draped sterily. Using ultrasound guidance, the AV fistula was accessed near the arteriovenous anastomosis in the left upper extremity. The guidewire was passed proximally using fluoroscopy and micropuncture sheath was inserted over the wire. The wire and dilator were removed and antegrade and retrograde angiography of the left upper extremity AV fistulogram was obtained with hand injection of optiray contrast. The arteriovenous anastomosis was widely patent. The fistula was brachiocephalic in construction. There was 50% stenosis 2-3 cm in length in the upper arm. The remainder of the fistula was at least 8 mm in diamter without focal stenosis. A 6mm balloon was inserted after exchanging the micropuncture sheath out to a brite tip 5 french sheath. A 6mm balloon was positioned at the anastomosis site and inflated. Stricture was evident with balloon inflation and this relazed nicely. THe balloon was deflated and followup angiography demonstrated some remaining narrowing in the area due to elasticity or perhaps under sizing of the balloon. There, an 8 mm balloon was advanced to the same location and inflated. Following this there was no residual evidence of narrowing in the area. The balloon and wire were withdrawn. Pressure was held for hemostasis. There still was presence of pulsatile flow in the fistula leading me to suspect that there is some central venous stenosis present. I elected to place a right internal jugular tunneled hemodialysis catheter in the event that there are some problems with flow in the fistula considering clinical suspicion of some remaining central outlet obstruction.
The right neck was prepped and draped sterily. 1% lidocaine was infiltrated. Under ultrasound guidance, the internal jugular vein was punctured, which was small in caliber. Attempt to pass a wire under fluoroscopy was not successful, the wire would only go 3cm in the internal jugular. Micropuncture sheath was inserted over the wire and the wire was withdrawn and hand injection of opitray contrast was performed to obtain a central venogram to evaluate why the wire would not pass. The cause of immediately apparent. the internal jugular vein was quite small and tortuous, owing no doubt to multiple hemodialysis catheter placements in the past with probable near total occlusion of the internal jugular and there was no drainage into the central venous system evident on the venogram. This vein is not suitable for insertion of any type of catheter and the left subclavian was then attemped to be accessed. The vein was punctured. A nice return of blood was obtained. The wire would not pass here either under fluoroscopy. At this point I suspected there was diffuse central venous stenosis and disease with previous accesses, and attempts were abandoned. Sterile dressing was applied. A postop chest xray was ordered to rule out pneumothorax. The patient was transferred to the recovery room.
Brooke Bierman, CPC, CPB
Coding & Billing Manager
2014 President AAPC Des Moines Chapter