Ask Dr. Z

Hi Dr. Z - I have a case in which the MD is calling a revision of an AV fistula (36833) but I think it is a creation of a new fistula (36830). Additionally, I am not certain if the diagnostic venogram performed via cutdown at the cephalic vein would be reported as 36147, 75791 or 75820. The H&P indicates that the old fistula is a left radial cephalic AV fistula which has occluded. The procedure is as follows: "Findings: 1. a newly created graft was constructed with good flow noted…findings of the upper extremity cephalic vein showed it to be a short course vein with occlusion. INdications: This patient presented with ESRD and underwent AV fistula which failed. He presents for revision…Procedure: …US was used to find the patients old AV anastomosis…I could not find any portion on tracking that was not clotted. In light of that I made a cut down over the cephalic vein at the antecubital fossa, dissected out for a short distance, and then cannulated this…venogram showed cephalic vein occlusion but a reasonable upper extremity brachial vein for access. Central venous runoff was w/o occlusion. With this in mind, I elected to convert to a new graft and continued the incision up into the upper arm to expose the brachial artery. With dissection the brachial artery carried out and the brachial vein was dissected through an upper arm incision in the deep fascia and mobilized for anastomosis. A tunnel was created and a flixene graft passed through the tunnel. The venous end of the graft was cut a venotomy was performed and the graft spatulated and sewn end to side to the venotomy…the arterial end was then approached. The brachial artery was opened…the end of the graft was sewn end to side to the artery...". Thanks in advance for your help!