Pre-op Diagnosis: Stenosis of the proximal arteriovenous fisutla
Post-op Diagnosis: Same as Pre-op
Procedure(s): Left – Arteriovenous Fistulogram with angioplasty and stent graft placement
Proc. Description(s) & CPT Code(s): Arteriovenous Fistulogram:
Anesthesia: Procedural Sedation
Estimated Blood Loss: Minimal
Drain: none
Total IV Fluids: minimal
Specimens: No specimens
Complications: none
Disposition: aroused from sedation, and taken to the recovery room in a stable condition
Condition: doing well
Anesthesia: Monitored Local Anesthesia with Sedation
Anesthesia start time:06:59
Anesthesia stop time: 07:37
Read also: Coding guide for AV fistual CPT code 36901
Coding guide for Stent placement in AV fistulat
Anesthesia Meds
Versed:1 mg
Fentanyl:50 mcg
Anesthesia Protocol in greater detail: The patient was placed in the procedure room. The patient was immediately connected to a continuous pulse oximeter device, a continuous EKG monitor, and automatic blood pressure cuff cycled every 5 minutes. The patient was monitored by a registered nurse with ACLS training who is only responsibility was to monitor the patient during the case. This nurses experienced in the administration of sedation and a cath lab study under physician direction. In this case I was the directing physician.
Complications: extravasation with hematoma proximal fisutla
Findings:
- 70 % stenosis of the brachial artery at the anastomosis
- 50% stenosis of the proximal fistula
- No central vein stenosis
- Right internal jugular vein tunneled dialysis catheter in good position
Procedure in detail:
- Fistulagram with angioplasty and stent graft placement
- Supervision and monitoring of IV conscious sedation for 38 minutes
The patient was brought into the cath lab. The patient was placed on the cath lab table of the anesthetic protocol noted above was instituted. We then prepped and draped the patient in a sterile fashion exposing the proximal fistula. We then infiltrated with local anesthesia and placed a micropuncture sheath. We confirmed that we were in the fistula with a bolus of contrast. We then treated the micro puncture sheath over a wire for a 6 French sheath. We injected contrast and obtained angiographic images from the sheath to the superior vena cava. We noted no distal stenosis. We noted no central vein stenosis. We noted a tunneled dialysis catheter in good position with the tip at the cavoatrial junction. We then advanced a Bernstein catheter through the proximal anastomosis into the mid brachial artery and performed angiography.
We noted a 70% focal stenosis of the brachial artery at the anastomosis and a 50% stenosis of the proximal fistula which we initially thought was probably an artifact of the sheath placement. We administered a small dose of heparin and then dilated the proximal anastomosis and proximal fistula with a 6 mm drug coated balloon inflated to full effacement. We pulled the balloon back and dilated the more proximal stenosis (angioplasty done). We noted an immediate development of hematoma and angiography confirmed extravasation in the proximal fistula. We then rapidly exchanged over an 035 wire for a 7 French sheath. We then exchanged for an 018 wire. We then deployed a 7 mm x 50 mm via bond stent graft (Stent placement) in the proximal fistula and post dilated with these 6 mm balloon inflated to 6.5 mm in diameter. Subsequently angiography noted no further extravasation. The hematoma remained stable the patient was noted to have an improved thrill in the fistula. We pulled the sheath and sutured the puncture site. The patient tolerated the procedure well and was taken to his room in stable condition
Implants: 7 mm x 5 cm Viabahn stent graft in the proximal fistula
The patient tolerated the procedure well. The patient was awakened from sleep and returned to his room in stable condition.
CPT code 36903 – Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiologic supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiologic supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment
Moderate Sedation coding (total time 38 minutes 6.59 to 7.37)
99152 – First 15 minutes
99153- additional 15 minutes
99153 – additional 8 mintues