# Revision AV Fistula/Angiogram/Angioplasty



## hpierce (Jan 16, 2013)

Can I bill anything other than 36833 for this one? Thanks!

PREOPERATIVE DIAGNOSIS:
     Malfunctioning dialysis access.
POSTOPERATIVE DIAGNOSIS:
     Malfunctioning dialysis access.
PROCEDURES:
     1.  Revision of arteriovenous fistula.
     2.  Angiogram arteriovenous fistula.
     3.  Angioplasty arteriovenous fistula.
INDICATION FOR PROCEDURE:
     This 49-year-old lady has an AV fistula in her right upper arm. I believe, the basilic vein transposition fistula from about a year and a half ago, and this was recently found to be thrombosed.  Dr. X attempted to open this up in Interventional Radiology, did in fact get it open but could not get the clot out, but flow in it remained pretty weak and feeble, but it did have flow in it and therefore thought it was worth an attempt to surgical declot.  I also felt fairly sure that there was stenosis down in the arterial line and the anastomosis which could be identified on Dr. Foust's angiograms.
FINDINGS:
     I was able to get a lot of clot out of the fistula and this was fairly organized clot ______ been in there, but it was pretty tough.  I then performed an angiogram of the arterial end of the fistula.  This showed tight stenoses down close to the arterial anastomosis.  The first segment from the artery of about 2 cm is patent.  There has been a very tight stenosis at the level of the previous veno-venous anastomosis and then some slightly less tight stenoses running over the course of 1 cm or 2 cm.  Then, these were successfully dilated with a 6-mm Conquest balloon, and the followup angiogram showed a significant improvement in diameter of the vein.  I then also shot an angiogram of the venous end of anastomosis.  This showed that the vein was patent, although it appeared a little narrow and the stent graft that was also patent.  There appeared to be one area of stenosis or more likely residual clot just upstream from the stent graft. I did try and run the Fogarty balloon catheter through this a couple of more times but could not get any clot out.  I did not want to be too aggressive with the stent right next to it. At the end of the procedure, there appeared to be good pulse and thrill in the fistula, and I think this should be reasonably successful procedure.  However, I planned to send her back to Interventional Radiology in about a week or two to have this restudied and see if she needs any further work by then. 
     DESCRIPTION OF PROCEDURE:
     The patient was taken to the operating room, placed under sedation underneath the observation of anesthesiologist.  Her right arm was prepped and draped in the usual sterile fashion. I then infiltrated the skin and subcutaneous tissues at the level of the incision for the original arterial anastomosis, also at the upper arm at the site of the original counterincision used up at the top of the upper arm, and then also in the middle of the fistula, which I estimated to be a point where a rather aneurysmal dilated portion of the fistula narrowed into a more narrow portion, which is where the clot appeared to be.  Once these areas were infiltrated, I made a transverse incision at the top and bottom of the arm, dissected free the fistula and both these areas, and controlled it proximally and distally with vessel loops.  I then made a longitudinal incision in the middle of the fistula, dissected free a segment about 2 to 3 cm of the fistula itself.  Then, the  patient was injected with 6000 units of heparin IV.  We then  clamped the fistula proximally and distally.  I then opened the fistula in the middle in a transverse fashion.  I scooped as   much plugs I could and then I got a Fogarty balloon catheter and ran this distally and dragged back until there was no more clot coming back and flushed the distal portion with heparinized saline and repeated this back towards the arterial anastomosis. I then tried to pass a vein dilator down towards the arterial anastomosis, even a 1-mm vein dilator would not pass. Therefore, I placed a 7-French introducer into the arterial end of the fistula and held in place with a vessel loops.  I then shot the initial angiogram of the arterial end of the fistula with an Optiray and this demonstrated the stenosis.  I then,     under fluoroscopic guidance, ran a guidewire down the introducer into the artery distally down the forearm.  I then passed a 6 mm x 4 cm Conquest angioplasty balloon over the guidewire under fluoroscopic guidance positioning in, so that the distal tip of the balloon was just downstream from the artery to try and avoid  jeopardizing arterial anastomosis.  I then inflated the balloon; the first time to about 25 atmospheres, the second time to about 20 atmospheres.  This appeared to give a good dilation of the stenosis.  We then withdrew the catheter out of the way and shot the completion angiogram of the arterial end which looked a good deal better, although still the diameter down this end is kind of small.  I then flushed the arterial end of the fistula with heparinized saline and clamped it off.  I then turned the introducer around and inserted in to the venous end.  I shot the
     venous fistulogram with the results as described above.  I then tried to pass the balloon catheter a few more times without getting more clot and flushed the venous end of the graft with heparinized saline.  With the graft clamped proximally and distally, I then oversewed the incision I had made in the venostomy and closed this with continuous 4-0 Prolene suture on  RB-1 needle.  Once I was satisfied with this, I removed the venous clamp first.  I did not get very much in way of backflow but then I removed the arterial clamp.  There appeared to be adequate forward flow, had a pulse and thrill in the fistula, and at this point, I felt we probably achieved or I could ______ today, and therefore, I closed subcutaneous tissues with 3-0 Vicryl, closed the skin with 5-0 Monocryl.  I did not see any bleeding from this at the end of the procedure.  Patient was taken to recovery room.  Estimated blood loss was 100 to 200 cc.  No complications.


----------

