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Hello,

For this case I have the angioplasty and fistulagram 75791. Don't know if I should charge the cephalic transposition 36818 because 2 incisions were not done to tunnel a vein, just subcu tissue was closed underneath to raise the vein. And don't know if a ligation counts. Does there have to be a know problem with colaterals and a seperate incision done to charge a ligation? I think a revision was not done to code that because in a revision there is a new anastomosis created with or without thrombectomy. Do I just charge the fistulagram and pta, or is there anything else appropriate to charge? Thanks,
Jenny



INDICATIONS: The patient is status post left brachiocephalic AV fistula. The vein is deep and ultrasound shows a central vein stenosis.

FINDINGS: The cephalic vein in the upper arm was nicely dilated. Fistulogram showed a high-grade stenosis at the cephalic vein just prior to the junction with the subclavian vein. Following angioplasty with a 5 mm cutting balloon, there was significant residual stenosis. Following angioplasty with a high-pressure 8 mm Dorado balloon, there was good flow through the fistula and the subclavian, innominate vein and superior vena cava were widely patent. Following transposition, there was an excellent palpable thrill through the arm.

PROCEDURE: The patient was identified and brought to the operating room. She was placed in the supine position. Her left arm was prepped and draped in standard fashion. An incision was made along the cephalic vein from the elbow to the upper portion of the upper arm and extended down through subcutaneous tissue. The cephalic vein was dissected circumferentially. Through a large side branch, a 5-French sheath was placed and then a fistulogram and central venogram was performed. The patient was given heparin and a wire was advanced across the cephalic vein stenosis. A 5 mm x 2 cm VascuTrack balloon was advanced to the area and angioplasty was performed. Follow-up angiogram showed residual stenosis and therefore, an 8 mm high-pressure balloon was advanced across the anastomosis and angioplasty was performed. Following angioplasty, there was good flow to the AV fistula. Subsequently the sheath was removed and the side branch oversewed with Prolene. The remainder of the side branches were ligated and divided and the cephalic vein was circumferentially dissected. Subsequently, the subcutaneous tissue plane was closed underneath AV fistula elevating it to a more superficial position. Subcutaneous flaps were created on either side and then the top portion of the wound was closed in layers.