Ask Dr. Z

How would you code a percutaneous AV graft ligation or collateral veins? I have three examples: Example #1) Two stab incisions were made at the site of the collateral once local anesthesia was infiltrated. Under direct ultrasound guidance, a Hawkins needle was passed deep to the collateral vessel from one incision out the next. Example #2) The collateral vein was identified with ultrasound, which demonstrated an early bifurcation. Under ultrasound guidance, a curved needle was used to guide 4-0 silk sutures around the larger branch, which was subsequently tied off. Example #3) Under ultrasound guidance, a Hawkins needle was advanced deep to the juxta-anastomic venous outflow segment, and a 0-0 silk suture was pulled through the soft tissues and out the skin. The Hawkins needle was then advanced superficial to the vein remaining deep to the skin, and the 3-0 silk suture was pulled in reverse through the soft tissues and out the skin. A surgical knot was tied down, reducing the diameter of the juxta-anastomotic venous segment to 5 mm.