# AV shunt intervention



## stgregor (Jan 17, 2011)

Based on the new, current SIR guidelines, as I understand them, only the arterial PTA should be coded when both the arterial and venous ends of the AV fistula are treated, correct? Venous is only to be coded if it's the only portion treated or if a vein outside the fistula is treated.

Based on this, what are your thoughts on coding for the below? I get: 36147, 36148, 35475, 75962. I don't see separate access or justification for any selective caths or venography/angiography as is described in the report. 76937 is bundled.

Any assistance you can provide is greatly appreciated! Thanks!

INDICATION: The patient is a 63-year-old male with end-stage renal
failure status post left upper arm dialysis fistula placement.
Evaluation is requested because of diminished dialysis flow rates.

PROCEDURAL STEPS
1. Ultrasound-guided antegrade percutaneous access of the dialysis
fistula.
2. Fistulogram.
3. Ultrasound-guided retrograde percutaneous access of the dialysis
fistula.
4. Selective catheterization of the brachial artery.
5. Percutaneous transluminal angioplasty of the dialysis fistula,
arterial end.
6. Repeat antegrade percutaneous access of the dialysis fistula.
7. Percutaneous transluminal angioplasty of the venous end.
8. Post angioplasty fistulogram.
9. Upper extremity venogram.

PROCEDURE
After informed consent was obtained, the patient was placed supine on
the angiography table. The left upper arm was sterilely prepped and
draped. The skin and underlying soft tissues were locally
anesthetized with buffered 1% lidocaine. A small skin nick was then
made. Under ultrasound guidance, using a micropuncture needle set,
the dialysis was percutaneously accessed antegrade at a point
approximately 2 cm proximal to the AV anastomosis. A 0.018-inch
guidewire was passed over which a 4-French coaxial dilator was
passed. The guidewire and inner dilator were removed and subsequent
injections were carried via the 4-French dilator. This, however,
immediately showed that there was catheter occlusion with stasis of
flow noted within the fistula. The dilator was therefore removed and
pressure held until hemostasis was obtained.
Subsequently, under ultrasound guidance, retrograde percutaneous
access of the dialysis fistula was achieved followed by placement of
a 6-French bright-tipped sheath, retrograde. A 0.035-inch guidewire
was selectively passed across the arteriovenous anastomosis into the
brachial artery. Over this, a 4 x 40 mm angioplasty balloon catheter
was passed and serial balloon angioplasty of the arterial end of the
dialysis fistula was performed. The balloon catheter was removed and
subsequent fistulogram was obtained showing an improved appearance to
the arterial flow.
Repeat antegrade performed access using the micropuncture needle set
of the dialysis fistula is performed. In an antegrade direction, a
6-French bright-tip sheath was placed. A 0.035-inch guidewire was
passed across the distal aspect of the fistula. Over the wire, a 7 x
40 mm balloon catheter was passed and serial balloon angioplasty of a
venous outflow stenosis was performed. Follow up fistulogram was
obtained showing only minimal improvement. Subsequently, an 8 x 40 mm
angioplasty balloon catheter was passed and repeat balloon
angioplasty of the venous stenosis was performed. Balloon catheter
was removed and a subsequent fistulogram was obtained. Subsequently,
a left upper extremity venography was performed. Guidewires were
removed. Pursestring sutures were then tied about both fistula access
sites and the sheaths were removed. Once hemostasis was obtained,
sutures were then removed and sterile bandages were applied. The
patient tolerated the procedure well with no immediate complications.

FINDINGS
An end-to-side anastomosis is seen of the cephalic vein to the
brachial artery immediately above the level of the level. Although
the arteriovenous anastomosis is patent, the immediate outflow
cephalic is diffusely small in caliber with a high-grade focal
stenosis seen approximately 3-4 cm proximal to the AV anastomosis.
Approximately 10-12 cm proximal to the AV anastomosis, there is a
venous outflow stenosis of approximately 70% over a less than 1 cm
length. The remainder of the cephalic vein and central veins appear
unremarkable without flow limiting lesions.
Following balloon angioplasty, there is improved appearance of both
the arterial and venous ends of the dialysis fistula without
significant flow limiting lesions. Brisk flow is demonstrated
throughout. There is no extravasation seen.

CONCLUSION
Tandem stenosis involving dialysis fistula located approximately 3-4
and 10-12 cm proximal to the AV anastomosis. Status post percutaneous
transluminal angioplasty at both of these lesions without significant
residual flow limiting lesions identified.


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## dimmitta (Jan 18, 2011)

*RE: AV Shunt Intervention*

I believe you have coded this correctly. I agree that there is no justification to code for any selective caths or venography/angiography as is described in the report. These are the codes I would have selected


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