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Arterial angiography during dialysis fistula/graft evaluation
Date: Jul 16, 2012
Question:
Is this one where you would use 75791 and a selective cath. Code? 36215?
Thanks!
TECHNIQUE: The risks, benefits and goals of dialysis fistula/graft evaluation with possible stent placement and possible angioplasty under conscious sedation were discussed with the patient prior to the procedure. The patient desired to proceed and signed informed consent. The patient was placed supine on the angiography table. The left upper extremity was prepared and draped in the usual sterile fashion. 2% lidocaine with epinephrine was used as a local anesthetic. Access to the fistula was obtained using US guidance and micropuncture technique directed toward the arterial inflow. Evaluation of the fistula outflow was performed with digital subtraction venography to the level of the right atrium. Reflux imaging of the arterial anastomosis was also performed. An angled glidewire was inserted and passed into the radial artery above the anastomosis, under direct fluoroscopic observation. A Kumpe catheter was inserted, and digital subtraction angiography of the radial artery was performed.The catheters and wires were withdrawn. Hemostasis was obtained with manual compression. During the process of obtaining hemostasis, a hematoma formed around the fistula, and extended along a portion of the fistula causing compression of the outflow. This resulted in a decreased thrill and increased fistula pulsatility. Additional pressure was held. The hematoma was massaged to soften it. Repeated US evaluation of the fistula was performed, demonstrating decreasing mass effect on the fistula. There was also an improvement in the exam, with increased thrill along the fistula. The patient tolerated the procedure well and exited the angiography suite in stable condition.
FINDINGS: There is brisk flow through the brachial artery-basilic vein fistula. The outflow is widely patent. The arteriovenous anastomosis is widely patent. There is sluggish distal flow in the brachial artery distal to the anastomosis, consistent with a steal phenomenon. US evaluation of the fistula after removal of access demonstrates a hematoma along the fistula, with mass effect on the fistula. The radial pulse remains strong.
IMPRESSION: 1. Widely patent left upper arm brachial artery-basilic vein fistula. Difficulty accessing the fistula may be related to its depth.
2. Finding consistent with a steal phenomenon. This corresponds with patient's complaint of poor circulation to his left hand, which is more pronounced during dialysis.
3. Post-procedure peri-fistula hematoma as described above.
Thanks!
TECHNIQUE: The risks, benefits and goals of dialysis fistula/graft evaluation with possible stent placement and possible angioplasty under conscious sedation were discussed with the patient prior to the procedure. The patient desired to proceed and signed informed consent. The patient was placed supine on the angiography table. The left upper extremity was prepared and draped in the usual sterile fashion. 2% lidocaine with epinephrine was used as a local anesthetic. Access to the fistula was obtained using US guidance and micropuncture technique directed toward the arterial inflow. Evaluation of the fistula outflow was performed with digital subtraction venography to the level of the right atrium. Reflux imaging of the arterial anastomosis was also performed. An angled glidewire was inserted and passed into the radial artery above the anastomosis, under direct fluoroscopic observation. A Kumpe catheter was inserted, and digital subtraction angiography of the radial artery was performed.The catheters and wires were withdrawn. Hemostasis was obtained with manual compression. During the process of obtaining hemostasis, a hematoma formed around the fistula, and extended along a portion of the fistula causing compression of the outflow. This resulted in a decreased thrill and increased fistula pulsatility. Additional pressure was held. The hematoma was massaged to soften it. Repeated US evaluation of the fistula was performed, demonstrating decreasing mass effect on the fistula. There was also an improvement in the exam, with increased thrill along the fistula. The patient tolerated the procedure well and exited the angiography suite in stable condition.
FINDINGS: There is brisk flow through the brachial artery-basilic vein fistula. The outflow is widely patent. The arteriovenous anastomosis is widely patent. There is sluggish distal flow in the brachial artery distal to the anastomosis, consistent with a steal phenomenon. US evaluation of the fistula after removal of access demonstrates a hematoma along the fistula, with mass effect on the fistula. The radial pulse remains strong.
IMPRESSION: 1. Widely patent left upper arm brachial artery-basilic vein fistula. Difficulty accessing the fistula may be related to its depth.
2. Finding consistent with a steal phenomenon. This corresponds with patient's complaint of poor circulation to his left hand, which is more pronounced during dialysis.
3. Post-procedure peri-fistula hematoma as described above.
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