Angio of AVF from 2 access points

Can someone please help me with this? The 2 different accesses are confusing me. Would I still only use 3614, 36148, and 45475/75962, or something in addition? Any thoughts are appreciated!

PROCEDURES PERFORMED:

FISTULOGRAM. RIGHT SUBCLAVIAN AND BRACHIAL ARTERY ARTERIOGRAM.

BALLOON ANGIOPLASTY BRACHIAL ARTERY STENOSIS.

BALLOON ANGIOPLASTY VENOUS ANASTOMOTIC STENOSIS.

IMAGING MODALITY UTILIZED:

Fluoroscopy and ultrasound.

MODERATE SEDATION:

Moderate sedation was utilized. ACCESS SITE:

Right brachial artery, right common femoral artery, AV loop graft.

CATHETER POSITION:

Brachial artery via the femoral approach, brachial artery via the brachial

approach, basilic vein via the graft approach.

CONTRAST UTILIZED:

Nonionic contrast utilized.

TECHNIQUE:

Sterile technique and local anesthesia was utilized. It was initially

attempted to access all of the pertinent anatomy via an antecubital

brachial approach. The brachial artery in the antecubital fossa was

punctured with ultrasound guidance and micro-puncture technique. A 4

French dilator was introduced into the brachial artery. Test injection of

contrast demonstrated a high-grade stenosis at the anastomosis of at least

80-90 percent. A 4 French dilator was nearly occlusive in this area. The

patient was administered 4000 units of heparin. The 4 French dilator

removed. Hemostasis achieved. This approach was abandoned.

Via the right transfemoral approach utilizing standard technique the right

subclavian artery was selectively cannulated. A subclavian arteriogram,

brachial angiogram, brachial arteriogram was performed. There is calcific

plaque in the subclavian artery.

There is low grade, less than 50 percent axillary artery stenosis. No

proper subclavian artery stenosis is seen. 90 percent stenosis of the

brachial artery at the arterial anastomosis was identified.

Upon subclavian injection the AV loop graft and venous anatomy is well

seen. There is a 60 percent stenosis at the venous anastomosis. Otherwise

the axillary vein, subclavian vein, brachiocephalic vein and superior vena

cava are patent.

INTERVENTION:

Considering patient's symptoms it was elected to proceed with balloon

angioplasty of the brachial stenosis. This was accomplished via the right

femoral approach. Utilizing standard technique a long 6 French sheath was

advanced to the proximal brachial artery. The stenotic lesion was traversed

without incident. Utilizing a 0.018 inch platinum tipped guidewire the

area of stenosis was dilated with a 4 mm x 40 mm balloon catheter.

Completion study shows an excellent result with no residual narrowing.

The long 6 French sheath was removed over a wire and the femoral puncture

was closed with a Star Close closure device.

At this point the right AV loop was punctured directed towards the venous

anastomosis. The patient had been administered an additional 1000 units of

heparin during the brachial artery angioplasty. The stenosis at the venous

anastomosis was dilated with a 7 mm x 40 mm high-pressure balloon with good

result. No residual narrowing or complications were encountered.

COMPLICATIONS:

None.

IMPRESSION:

THE DIAGNOSTIC EXAMINATION HAS DEMONSTRATED HIGH-GRADE BRACHIAL ARTERY

STENOSIS AT THE ARTERIAL ANASTOMOSIS SUCCESSFULLY TREATED WITH BALLOON

ANGIOPLASTY.

Angio of AVF from 2 access points