Ask Dr. Z

Dr Z, I am not sure if the procedure described in the below op report would be considered a revision or new creation and whether or not the ligation of the collateral vein can be reported separately. Any clarification you can provide is appreciated. A patient has a nonmaturing distal radial AV fistula who came for evaluation. The fistula was cannulated and shuntogram performed (36147). The vein immediately after the anastomoses showed significant stenosis with flow through through collaterals with no flow through the main fistula. Arterial anastomosis was found to be adequate but the radial artery was small in caliber. Ligation of fistula performed and a portion of the cephalic vein more lateral and superior in location is found to be adequate and dissected proximally and distatlly with the side branches of the same being ligated. The vein is then cannulated and venogram of the upper extremity as well as central venous and SVC performed. Other than the cephalic vein being small, no stenosis or obstruction noted on studies. Dissection of radial artery was then performed and a longitudinal arteriotomy wsa performed. An angioplasty in the proximal portion of the artery was performed followed by angioplasty of the cephalic vein. (No codes as I believe angioplasties were done due to the finding they were small vessels and would be considered part of the revision or creation of the fistula.) The anastomosis of the two were performed in an end-to-side fashion (36821 or 36832 - creation vs revision). Once completed, flow was obtained. Incision is closed. There is a collateral branch arising from the cephalic vein that was visualized on angiogram. A separate incision was performed and vessel ligated (37607?).