Coding assigned: 36901 and 36907 ICD-10 T82.858A T82.868A N18.6 and Z99.2
Summary
Access type: Right Brachial A-Basilic V arm non-transposed AVF
Right unilateral upper extremity fistulogram
Subclavian vein: angioplasty
Contrast type: Omnigpague 18cc (LOCM 300-399mg/ml iodine, 1ml)
Closure type-sutured
Technique:
The patient as brought to the endovascular suite, placed in a supine position and draped in routine sterile fashion. All aspects of the time-out verification were satisfactorily completed prior to the beginning of the procedure. The right upper extremity was prepped using Chloraprep. Moderate sedation/analgesic(conscious sedation) administered with critical care nurse to monito the level of consciousness and physiological status for the total of 30 min(s) using 100 mcg Fentanyl and 1 mg versed. The lower basilic vein was accessed in an antegrade fashion using an 18 gauge needle. A guide wire was introduced through the needle. The needle was removed and a 4-FR sheath was advanced. The sheath was flushed and fistulogram was performed. After carefully reviewing the diagnostic fistulogram, it was decided to proceed with intervention. The 4-Fr sheath was removed and upsized for 7-Fr sheath.
Intervention:
A catheter was placed over the wire in the subclavian vein. A 12 mm x40mm balloon angioplasty was performed on the vessel
Hemostasis:
All wires, catheters and sheaths were removed. The puncture site was sutured.
Findings:
Subclavian vein: occluded
Post Intervention Findings:
The residual stenosis is 40% in subclavian vein
Conclusions:
Successful, uncomplicating recanalization and treatment of outflow central venous occlusion at right subclavian vein with high pressure 12 mm balloon angioplasty as described above
This access is ready for use as needed. Given the high likelihood of recurrent stenosis/occlusion, it is recommended that this patient be clinically evaluated for possible repeat intervention in 3 months. From our standpoint, this access is useable. There is a superficial segment near the arterial anastomosis in the antecubital fossa involving the median cubital vein/ lower basilic vein that courses over the medial epicondyle that is easily palpable and of sufficient caliber before plunging far too deep in the upper arm basilic vein component. We recommend that using this portion should be attempted now. To facilitate cannulation the desired cannulation zones were marked on the skin with a magic marker. Depending on how this goes, a decision to revisit superficialization/transportation surgery can be reconsidered. If access continues to give difficulty and is never going to be transposed/superficialized, then access ligation at the arterial anastomosis is recommended to lessen likelihood/severity of recurrent symptomatic right subclavian vein occlusion.