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Would you bill 36556, 76937-52 or 36556, 71010? Thanks!

Placement of left subclavian vein temporary Vas-Cath

Indication: This is a 60-year-old female with end-stage renal disease on dialysis via a left internal jugular permacath. She had previously failed all AV fistula and graft options. Unfortunately she developed a fungemia and required removal of her permacath. We were consulted for temporary access while she is being treated for the fungemia. All risks and benefits of the temporary line were explained to the patient prior to the procedure. I told her that I would initially start by looking at her jugular veins with ultrasound to determine which side is either or suitable for current temporary access. If those are not an option we will plan for a subclavian catheter.

Procedure details: The patient was brought into the treatment room and left on her hospital bed for the procedure. She was laid flat with a blanket placed under her shoulder blades. She was placed in Trendelenburg position. I began by using an ultrasound to evaluate her jugular veins. On the right side it was apparent that her jugular vein drained into a thyroidal branch and that there were extensive small collateral vessels beyond that but no patent jugular vein in the lower neck. On the left side she had evidence of a very small jugular vein where her previous permacath had just been pulled from, however it was very scarred down, not compressible, and I lost visualization of it in her lower neck. I therefore made the decision to attempt access of her left subclavian vein for the catheter placement.

A time out was performed. The patient's left chest was prepped and draped in the usual sterile fashion. Maximal sterile barrier technique was used throughout the entire procedure. A time out was performed. The left chest wall and periosteal clavicular space was anesthetized with 1% plain lidocaine. A single wall access needle was used to access the left subclavian vein using anatomic landmarks with 2 attempts. After obtaining a flash in the syringe a 0.35 Amplatz wire was placed without any difficulty. The needle was removed and a small skin incision was made with an 11 blade. The serial dilation was performed and a 12-French 18 cm Vas-cath was placed over the wire using Seldinger technique. The wire was removed and both ports flushed and withdrew easily. A total of 1000 units of heparin was injected into each port. The catheter was then sewn to the chest wall with 3.0 silk. The patient tolerated the procedure well with no complications. A chest x-ray was obtained post procedure showing the tip of the catheter in the proximal right atrium with no evidence of pneumothorax.

Result Impression

Successful placement of temporary left subclavian vein Vas-Cath without evidence of pneumothorax.

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