Should this be coded as 35206, 37607, 36821? I feel like this might be more of a revision of the old fistula with creation of a new fistula and that 36832, 36821-59 might be better.

The physician excised an aneurysmal radiocephalic fistula, then created a new brachiocephalic fistula.

Transverse incision made 1 cm below antecubital crease. cephalic vein identified and dissected circumferentially. a branch was selected for use. the distal vein was ligated and divided. bicipital aponeurosis was opened and the distal brachial artery was dissected out.

Elliptical incisions were made around each aneurysmal site in the forearm, small branches were ligated and divided. segments in the forearm were ligated and divided and handed off. the segment near the arterial anastomosis was dissected down to the radial artery.

The radial artery was clamped, the aneurysmal portion of the fistula was excised leaving a cuff of tissue over the radial artery, then the cuff of tissue was closed to reform the radial artery. Flow to the radial artery was restored.

The deep branch of the cephalic vein was now ligated and divided and the vein was brought over to the (distal brachial) artery. The artery was clamped proximally and distally and an arteriotomy was made.An end to side anastomosis was sewn between the vein and artery.