# brachiocephalic AV fistula



## churst21

The patient was brought into the operating room  
table, was then prepped and draped in a sterile fashion with chlorhexidine  
solution.  After giving the IV sedation and local anesthetic, the left arm was  
hyperextended and a radial artery was localized with ultrasound guidance using a
 21-gauge needle, it was accessed using a 1.018 wire, was selected the radial  
artery and a wire was placed into the brachial artery.  At this time, a micro  
sheath was then placed and then exchanged to a 5-French tapered transradial  
sheath and was inserted successfully.  At this time, the brachial angiogram was  
performed, demonstrated an occluded brachiocephalic AV fistula.  The  
brachiocephalic AV fistula was selected using roadmap.  A Glidewire and a glide  
catheter was selected successfully and Glidewire was then placed to the  
area of the cephalic arch followed by a glide catheter.  At this time, the  
Glidewire was then removed and a fistulogram was performed demonstrating to have
 a high-grade stenosis at the cephalic arch and occluded a brachiocephalic AV  
fistula.  At this time, the Possis machine was then used to infuse 4 mg of TPA  
at the AV fistula, it was left for a minute or two and a mechanical thrombectomy
 was performed with Possis throughout the AV fistula.  A repeat fistulogram  
demonstrated adherent clots with areas of stenosis throughout the AV fistula.  A
 6 x 100 balloon was angioplastied throughout the AV fistula with significant  
improvement.  A cephalic arch stenosis was seen and a 6 x 20 balloon was then  
used to dilate the area with improvement.  A repeat fistulogram demonstrated  
proximal brachiocephalic AV fistula stenosis and an 8 x 100 Dorado balloon was  
then used to angioplasty that area with an improvement on the fistulogram and  
had a pulsatile flow throughout the AV fistula.  A decision was to follow up and
 to continue medical therapy and to attempt hemodialysis access through the AV  
fistula.  All wires and sheath were removed and a transradial band was then  
inflated to around 15 mL of air and to keep inflated for 2 hours.

I'm stuck with the angioplasty part


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## dpeoples

churst21 said:


> The patient was brought into the operating room
> table, was then prepped and draped in a sterile fashion with chlorhexidine
> solution.  After giving the IV sedation and local anesthetic, the left arm was
> hyperextended and a radial artery was localized with ultrasound guidance using a
> 21-gauge needle, it was accessed using a 1.018 wire, was selected the radial
> artery and a wire was placed into the brachial artery.  At this time, a micro
> sheath was then placed and then exchanged to a 5-French tapered transradial
> sheath and was inserted successfully.  At this time, the brachial angiogram was
> performed, demonstrated an occluded brachiocephalic AV fistula.  The
> brachiocephalic AV fistula was selected using roadmap.  A Glidewire and a glide
> catheter was selected successfully and Glidewire was then placed to the
> area of the cephalic arch followed by a glide catheter.  At this time, the
> Glidewire was then removed and a fistulogram was performed demonstrating to have
> a high-grade stenosis at the cephalic arch and occluded a brachiocephalic AV
> fistula.  At this time, the Possis machine was then used to infuse 4 mg of TPA
> at the AV fistula, it was left for a minute or two and a mechanical thrombectomy
> was performed with Possis throughout the AV fistula.  A repeat fistulogram
> demonstrated adherent clots with areas of stenosis throughout the AV fistula.  A
> 6 x 100 balloon was angioplastied throughout the AV fistula with significant
> improvement.  A cephalic arch stenosis was seen and a 6 x 20 balloon was then
> used to dilate the area with improvement.  A repeat fistulogram demonstrated
> proximal brachiocephalic AV fistula stenosis and an 8 x 100 Dorado balloon was
> then used to angioplasty that area with an improvement on the fistulogram and
> had a pulsatile flow throughout the AV fistula.  A decision was to follow up and
> to continue medical therapy and to attempt hemodialysis access through the AV
> fistula.  All wires and sheath were removed and a transradial band was then
> inflated to around 15 mL of air and to keep inflated for 2 hours.
> 
> I'm stuck with the angioplasty part



I would code:
35475/75962 for angioplasty
36870 for thrombectomy
36147 access and fistulogram

HTH


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## donnajrichmond

dpeoples said:


> I would code:
> 35475/75962 for angioplasty
> 36870 for thrombectomy
> 36147 access and fistulogram
> 
> HTH



Danny - I'm not seeing arterial anastomosis angioplasty - can you tell me where?


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## dpeoples

donnajrichmond said:


> Danny - I'm not seeing arterial anastomosis angioplasty - can you tell me where?



Hey Donna,
You may be correct. My thoughts are this:

A few years back the AMA and Mcare agreed that arterial angioplasty of AV grafts/shunts should only be reported when both are performed. Two things suggest that is the case with this report:
 1) The radial artery (not venous access) was the _only_ access site, and 2)the term "brachiocephalic" suggest the treatment zone (brachial artery/cephalic vein). In my minds image, this is the zone of the anastomosis.

So, we must then choose between a venoplasty (35476/75978) or angioplasty
(35475/75962) so I refer back to the AMA/Mcare agreement.

Also,  from Dr. Z (2011)
"Angioplasty performed at the arterial anastomosis (or perianatomosis region) is coded wth 35475/75962 for this upper extremity intervention if it is the only stenosis treated".

I do wish the verbage was better, part of my reasoning is to err on the side of caution. A "plasty" was performed, and usually only one can be reported....(though there are exceptions).

clear as mud right?

HTH


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## churst21

dpeoples said:


> Hey Donna,
> You may be correct. My thoughts are this:
> 
> A few years back the AMA and Mcare agreed that arterial angioplasty of AV grafts/shunts should only be reported when both are performed. Two things suggest that is the case with this report:
> 1) The radial artery (not venous access) was the _only_ access site, and 2)the term "brachiocephalic" suggest the treatment zone (brachial artery/cephalic vein). In my minds image, this is the zone of the anastomosis.
> 
> So, we must then choose between a venoplasty (35476/75978) or angioplasty
> (35475/75962) so I refer back to the AMA/Mcare agreement.
> 
> Also,  from Dr. Z (2011)
> "Angioplasty performed at the arterial anastomosis (or perianatomosis region) is coded wth 35475/75962 for this upper extremity intervention if it is the only stenosis treated".
> 
> I do wish the verbage was better, part of my reasoning is to err on the side of caution. A "plasty" was performed, and usually only one can be reported....(though there are exceptions).
> 
> clear as mud right?
> 
> HTH



So the cephalic arch is it part of the graft?


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## dpeoples

churst21 said:


> So the cephalic arch is it part of the graft?



The term "brachiocephalic AV fistuala" means the graft is the brachial artery/cephalic vein. So, the cephalic vein is the outflow vein, and for treatment purposes is part of the graft.
HTH


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## donnajrichmond

dpeoples said:


> Hey Donna,
> You may be correct. My thoughts are this:
> 
> A few years back the AMA and Mcare agreed that arterial angioplasty of AV grafts/shunts should only be reported when both are performed. Two things suggest that is the case with this report:
> 1) The radial artery (not venous access) was the _only_ access site, and 2)the term "brachiocephalic" suggest the treatment zone (brachial artery/cephalic vein). In my minds image, this is the zone of the anastomosis.
> 
> So, we must then choose between a venoplasty (35476/75978) or angioplasty
> (35475/75962) so I refer back to the AMA/Mcare agreement.
> 
> Also,  from Dr. Z (2011)
> "Angioplasty performed at the arterial anastomosis (or perianatomosis region) is coded wth 35475/75962 for this upper extremity intervention if it is the only stenosis treated".
> 
> I do wish the verbage was better, part of my reasoning is to err on the side of caution. A "plasty" was performed, and usually only one can be reported....(though there are exceptions).
> 
> clear as mud right?
> 
> HTH



I agree that only one angioplasty code set can be coded within the graft/draining veins.  But CPT says the only time the arterial codes can be coded is if an angioplasty is performed at the arterial perianastomotic area.  Otherwise, angioplasties within the graft are venous.  
I think it needs to go back to doctor for clarification!


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## churst21

So after reading Dr. Z whole page on AV Shunt Interventionals I kinda understand a little bit on why you choose 35475/75962

"Upper Extremity
a.  Peripheral zone: Arterial anastomosis/peri-anastomotic region, intra-graft, venous anastomosis, and outflow veins up to and including the axillary vein (peripheral veins). This includes the basillic, brachial, and cephalic veins."

 "b. Central zone: Subclavian vein, brachiocephalic vein, and superior vena cava (central veins)"

"Angioplasty performed at the arterial anastomosis (or perianastomotic region) is coded with 35475/75962 for this upper extremity intervention if it is the only stenosis treated. If an upper extremity venous angioplasty (in the same peripheral zone) is also performed, only submit the arterial codes 35475/75962. The venoplasty codes are not submitted in this case. If a separate "native" upper extremity arterial angioplasty is performed (and it is separate from the arterial anastomotic region), then codes 35475-59/75962-59 may additionally be submitted."


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