# Brachial arteriotomy, thrombectomy, PTA of cephalic



## lclemen (Nov 28, 2012)

Can someone help me code these two reports?  This was on the same patient.  They were done on two different days.


1st day:
PROCEDURES: 
1.  Right mid brachial arteriotomy, antegrade to flow, micropuncture technique.  Later exchanged for a 6-French 5.5 cm sheath. 
2.  Brachial arteriogram with runoff through the AV fistula, cephalic vein, and subclavian vein to the right atrium. 
3.  Aspiration thrombectomy of the right cephalic vein from the AV fistula anastomosis back up through the next 8 cm or so. 
4.  PTA of the right cephalic vein and the right proximal radial AV fistula anastomosis. 
5.  Attempted Trellis thrombectomy - unable to negotiate the tight bend across the anastomosis so this was unsuccessful. 
6.  Repeat aspiration thrombectomy. 
7.  Sheath sutured in place. 

FINDINGS: 
1.  Right brachial and radial arteries widely patent with large diameter. 
2.  Right AV fistula occluded at the anastomosis.  
3.  After getting the wire through the AV fistula, there was heavy thrombus burden over the first 8 cm or so of the cephalic vein filling the ectatic to aneurysmal segment. 
4.  At the AV anastomosis, there appeared to be tight stenosis. 
5.  Cephalic vein and subclavian vein runoff to the right atrium, otherwise, patent with smooth borders and no stenosis. 
6.  Runoff to the hand was normal. 

INTERVENTION: 
1.  PTA of the cephalic vein with a 5 mm x 10 cm balloon in tandem and overlapping positions from the AV anastomosis proximal in the cephalic vein. 
2.  Aspiration atherectomy with the 6-French multipurpose catheter.  Significantly improved flow then. 
3.  Attempted to place the Trellis catheter for thrombectomy, but could not pass a catheter around the very tight angle at the anastomosis even with stiff wire support. 
4.  Repeat aspiration thrombectomy. 
5.  PTA across the AV anastomosis with a 6 x 20 mm balloon with improved diameter and flows.  This confirmed tight stenosis at the anastomosis. 
6.  Flow markedly improved and no further mechanical intervention attempted.  Will leave the arterial line in and continue heparin anticoagulation. 

ANTICOAGULATION: 
1.  Heparin 5000 units plus 2000 units. 
2.  ACT in the 190s at end of procedure. 

HEMOSTASIS: 
A 6-French short arterial sheath sutured in place, mid brachial artery antegrade placement. 

COMPLICATIONS: 
1.  None immediately apparent. 
2.  Will monitor with the arterial line in and IV heparin infusing. 

TECHNICAL NOTES, MODIFIERS, COMORBIDITIES: 
1.  Chronic renal failure, on chronic hemodialysis. 
2.  Thrombosis of the AV fistula, over 3 days old on presentation. 
3.  Heavy tobacco abuse history, a major contributor to the risk of thrombosis and fistula loss. 
4.  Diabetes mellitus type 2, diet controlled. 
5.  Catheter was placed on 10/23/2012, preparing for peritoneal dialysis. 


2nd day

PROCEDURE:   
1.  Right brachial arteriogram with runoff through the proximal radial AV fistula back to the right atrium. 
2.  Suture-assisted manual hemostasis. 

FINDINGS: 
1.  The AV fistula is patent throughout. 
2.  Extensive, residual thrombus in the ectatic portion of the cephalic vein limb of the AV fistula, mildly improved after 18 hours of heparin. 
3.  The AV fistula from the anastomosis to the ectatic segment is very irregular, has re-narrowed after dilation yesterday with a 6 mm balloon, and has new thrombus from yesterday, in spite of 18 hours on heparin. 
4.  Runoff above the ectatic segment is normal. 
5.  The brachial and radial arteries are widely patent with smooth borders. 

INTERVENTION: 
1.  Dr. Whalen came to the Cath lab and we discussed findings.  This is felt to be a nonviable fistula and no further intervention is felt to be appropriate.   
2.  Will plan to start peritoneal dialysis later today. 

ANTICOAGULATION: 
1.  None indicated.   
2.  IV heparin turned off. 

COMPLICATIONS: 
None apparent. 

HEMOSTASIS: 
1.  IV heparin turned off, no additional heparin given. 
2.  ACT 106 at end of procedure. 

TECHNICAL NOTES, MODIFIERS, COMORBIDITIES: 
1.  Chronic renal failure, on chronic hemodialysis. 
2.  Thrombosis of the AV fistula, over 3 days old on presentation. 
3.  Heavy tobacco abuse history, a major contributor to the risk of thrombosis and fistula loss. 
4.  Diabetes mellitus type 2, diet controlled. 
5.  Catheter was placed on 10/23/2012, preparing for peritoneal dialysis. 

Thanks.
Lisa,CPC


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## lclemen (Nov 30, 2012)

Can someone help me with this? I am new to Cardiology coding and I really don't know how to code this one.  Thanks.

Lisa


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