Ask Dr. Z

Dr. Z Please tell me if I'm on the right track with the following code: 36147 1st access 36148 2nd access 36870 Mechanical Thrombolysis 35476 Angioplasty 75978 S&I for angioplasty thanks, :) The venous side of the patient's hemodialysis access graft was then cannulated in an arterial direction using a 21-gauge needle and a 0.018-inch guidewire is introduced in the graft. Over the guidewire, a Cook micropuncture system is used to place a 5-French catheter in the graft. The catheter is then steered in the left brachial artery. A left brachial arteriogram is then performed. A total of 70 mL of Visipaque-300 was used during the exam. Nonionic contrast media was used because of the patient's history of renal failure. 30 mL was wasted. The graft is seen to anastomose to a high takeoff of the radial artery. There is no evidence of stenosis in the radial artery. There is no flow identified from the radial artery into the graft. This is consistent with complete thrombosis of the graft. The arterial side of the graft is then cannulated in a venous direction using a 21-gauge needle and a 0.018-inch guidewire is introduced in the graft. Over the guidewire, a Cook micropuncture system is used to place a 5-French catheter in the graft. The catheter is then steered to the region of the venous anastomosis of the graft. A small amount of contrast media was then injected. This shows 90% venous anastomotic stenosis. There is also 90% stenosis in the venous side of the graft. Thrombus is seen to extend to the level of the venous anastomotic stenosis. A metallic stent is identified across the venous anastomotic stenosis. Both catheters were then exchanged for 6-French sheaths. The patient then received 5,000 units of intravenous heparin. Mechanical thrombolysis is then performed on the graft using the Arrow percutaneous thrombectomy device. A 6 mm diameter angioplasty balloon was then placed across the arterial anastomosis of the graft and gentle balloon embolectomy and angioplasty was performed of resistant thrombus and stenosis at the arterial anastomosis of the graft.This occurs within a previously placed metallic stent. An 8 mm diameter angioplasty balloon was then placed across the intragraft stenosis in the venous side of the graft and the venous anastomotic stenosis. Balloon dilatation was then performed at several levels. A left arm arteriovenous fistulogram and left upper extremity venogram were then obtained. There is no residual thrombus at the arterial anastomosis of the graft after angioplasty and balloon embolectomy. There is no evidence of intragraft stenosis. There is no residual venous anastomotic stenosis after angioplasty. There is no stenosis identified in the left axillary vein, subclavian vein, brachiocephalic vein or superior vena cava. Both catheters were then removed and hemostasis was achieved at both puncture sites using silk suture.