# AV Fistula Creation & Ligation of AV Fistula



## Partha45

Please review the below procedure document and help us to proceed further.

After reviewing the procedures we have come to conclusion to for following CPT's  36821 & 37607.

My doubt is whether we could bill 37607 is along with CPT 36821 or else is not substantive to bill based on the below document. 

36821 - Arteriovenous anastomosis, open; direct, any site (eg, cimino type) (separate procedure)

37607 - Ligation or banding of angioaccess arteriovenous fistula

Procedure Description and Findings

Patient with end stage renal renal disease who is nearing requiring hemodialysis. She was evaluiated with a
venous mapping and was found to be a candidate for a left arm brachibasilic AV Fistula. Patient was explained and consented for the
procedure. Risks, benefits, and alternatives were discussed.

Patient taken to the OR and placed in the supine position and placed into general anesthesia without complication. Ultrasound was
used to mark the basilica vein and brachial artery. The entire left arm was prepped and draped in sterile fashion. She was given 1 mg
IV Ancef for antibiotic prophylaxis. 6cm incision was made proximal to the antecubital fossa with a #15 blade. Electrocautery was
used to divide the subcutaneous tissue. The basilica vein was visualized and seen to be suitable for AV fistula creation. The basilica
vein was dissected from the antecubital fossa to near the axilla. Side branches were ligated with 3-0 silk suture. After careful sharp
dissection of the entire length of the basilic vein, the anterior surface was marked with a surgical marker. 3-0 silk sutures were placed
in the terminal brances to the baslic vein in just distal to the antecubital fossa but were not tied. Attention was then turned to the
brachial artery. The brachial artery was dissected with sharp dissection after dividing the subcutaneous tissue with electrocautery.
The artery was dissected to a length of 4 cm and vessel loops were placed proximally and distally. A Gore tunneling device was used
to create a subcutaneous tunnel to superficialize the basilic vein. The patient was then given 5000 units of IV Heparin. 3 minutes
later attention was then turned to creation of the anastomosis. The distal basilic vein was ligated and Potts scissors was used to cut
the distal basilic vein. A 20 cc syringe with an angiocath was used to flush the basilic vein and was found to be easily flushable with
no kinks. The vein was then passed through the tunneling device. The vessel loops around the brachial artery were then tightened. A
#11 blade was used to make an arteriotomy in the brachial artery. Micropotts scissors were used to extend the arteriotomy to a length
of 5mm. Anastamosis was created using a 6-0 prolene suture. Prior to creation of the anastomosis the distal brachial artery was
backbled. Anastamosis was then completed. The venous clamp followed the the arterial vessel loops were released. Minimal
anasamotic ozzing was controlled by using a treatment of gelfoam-thrombin. A atrong thrill was felt in the proxmimal vein. Doppler
was used to evaluate appropriate signals in the proximal and distal basilic vein and brachial artery. Radial pulse at the wrist was
palpable. The wound was irrigated with bacitracin soaked saline. 2-0 and 3-0 vicryl was used to close the fascia and subcutaneous
tissues. Staples were used to close the skin. 10 mL .25% Marcaine was injected around the incision for local anesthesia. 4x4 and
perforated tape was used for dressing.

Patient was extubated and taken to the recovery room in stable condition.


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