Ask Dr. Z

Hi Dr. Z, I've gotten better at coding the peripherals since you were here in January. This is the first AV fistula procedure that's been done in our cath lab and with the G codes being deleted, I'm hoping you can help me. Here's what the doctor documented: The patient is a 34 year old male with the following indications: abnormal fistula duplex, failure to mature AV fistula . The patient has the following Comorbidities/Risk Factors: Hypertension, On Dialysis, Renal Failure Prior to PCI. DIAGNOSTIC PERIPHERAL VASCULAR PROCEDURE Under ultrasound and fluoroscopic guidance, the left AV fistula was locally anesthetized and accessed with a micro puncture needle using the standard percutaneous technique. After injection and visualization of the brachial AV fistula anastomosis, the microsheath was exchanged over a wire a short 6F Brite-tip was placed in the AV fistula. With occlusive pressure of the distal fistula, angiography was performed in mulitple views. PERIPHERAL ANGIOGRAPHIC FINDINGS Subclavian: There was severe stenoses at proximal anastomosis and inflow segment of fistula. There was normal flow through the mid and distal portions of the AV fistula. The brachial artery was normal in size and did not have any significant stenosis. The primary indication for PVI was abnormal duplex of stenosis fistula. Additional indications include: abnormal fistula duplex, failure to mature AV fistula. INTERVENTIONAL PERIPHERAL VASCULAR PROCEDURE PVI of the left AV fistula artery was indicated for failure to mature graft due to proximal stenosis. A 6F sheath was chosen for the intervention. This sheath gave good support in the left AV fistula. A heparin bolus was given. The lesion in the left AV fistula stenosis was crossed successfully with an 0.035 inch stiff angled Glide wire and a 4F multipurpose catheter. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon at the anastomsis of left AV fistula and brachial artery two times. The maximal inflation pressure was 3 and 6 atm. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon in the residual vein in the proximal left AV fistula artery three times. The maximal inflation pressure was 3,4 and 8 atm each time. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon at the anastomsis of left AV fistula and brachial artery. The maximal inflation pressure was 8 atm. We then inflated a 6.0mm diameter of 40mm length Dorado balloon in the proximal left AV fistula three times. The maximal inflation pressure was 6, 10 and 9 atm each time. Repeat angiography revealed improved flow in the fistula with mild residual stenosis and no evidence of compromise of the left brachial artery. I appreciate any guidance you can give me. Kathy