Ask Dr. Z

Dr. Z, I feel like I'm always having trouble determinig the right CPT code when it comes to angioplasty of fistula. Please see the example of Op note that I need help on. Thanks! The patient's left arm and right groin were prepped and draped in the usual sterile fashion. Initially 1% plain Xylocaine was infiltrated over the course of the left arm fistula just above the AV anastomosis. This area of the fistula was accessed percutaneously using a micropuncture set and a 6-French short sheath placed. A left arm fistulography was then performed from the level of the antecubital fossa to the right atrium and revealed a moderate stenosis of the cephalic vein at the level of the humeral head which was then balloon dilated using an 8-mm x 40-mm Conquest balloon with good result. At this time, the sheath was removed from the left upper arm and we tried to redirect our puncture toward the antecubital fossa but were not able to get into the fistula at this point despite trying multiple attempts. At this point, the percutaneous right femoral artery access was obtained and a 5 F short sheath placed. A retrograde right iliofemoral sheath angiography was performed and revealed a good caliber right common femoral artery at site of puncture. The patient was then given 4000 units of Heparin IV. An angled Glidewire was then passed through the 6-French sheath placed in the groin and passed to the level of the aortic arch and exchanged for a vertebral catheter, which was used to selectively cannulate the left subclavian artery followed by cannulation of the left brachial artery. Left brachial angiography was performed and revealed a severe stenosis of the fistula at the AV anastomosis. The vertebral catheter was exchanged for a 90-cm Shuttle sheath through which wire crossing of the area of stenosis of the fistula in the antecubital fossa was done followed by balloon angioplasty using 8-mm and 10 mm balloons with good result. There was still a residual stenosis noted to be present of about 20% just above the AV anastomosis.