Fistulagram coding assistance needed

This is what I came up with for this procedure:

36147, 36148, 36870, 37224

Would be grateful for any input or what I have missed.

PROCEDURE PERFORMED:

1. Fistulogram with dual access towards the inflow and the outflow of the fistula.

2. Pulse/spray administration of thrombolytic therapy for complete thrombosed AV graft.

3. AngioJet mediated thrombectomy before and after pulse/spray administration.

4. Angioplasty, extensive, of the inflow, of the arterial anastomosis throughout the graft, as well as at the level of the graft into the venous anastomosis.

5. Separate right femoral venous access and crossover into the left iliac artery and selective

angiogram of the left internal iliac into common femoral artery to identify the iliac stenosis.

INDICATION FOR THE PROCEDURE:

Patient with end stage renal disease on dialysis. After dialysis had developed complete thrombosis of AV graft in left thigh. It was a femoral arterial to venous sheath.

Informed consent was obtained from the patient after detailed description of risks and benefits. Patient was brought to the Catheterization Lab, prepped and draped in a sterile fashion. Following this, access was initially obtained towards the outflow of the AV graft and gentle injection showed extensive amount of thrombus towards the AV graft. Next, a short #6 French sheath was placed and a glidewire was used to cross into the venous system and gentle balloon dilatation using a 5 x 40 Mustang was performed to open up the outflow of the fistula. Next, AngioJet was used to thrombectomize the fistula first and after multiple runs, approximately 6 mg of TPA was pulse/sprayed into the graft and left to marinate for some time.

In the meantime, access was obtained towards the inflow of the fistula and using multiple wires it was not possible to cross across the AV junction. There was a very high grade stenosis or obstruction and it was not very clear where the AV junction was. Therefore, at this time,

contralateral femoral access was obtained and an IM catheter was used to go up and over and the head of the AV anastomosis was defined using multiple projections and multiple injections. Next, after a lot of difficulty, a PT wire was passed through the AV anastomosis into the external iliac artery. This was then swapped out for a standard J-wire and at this time, AngioJet mediated thrombectomy was performed on the inflow and pulse/spray was administered. Following this, pulse/spray thrombectomy was again performed in the outflow and the outflow now was widely open. There was some amount of thrombus material around the access site but most of the graft was widely patent.

Next, multiple injections showed that there was a 90% inflow stenosis at the level of the AV anastomosis. 6 x 40 Mustang balloon was used at high pressure to dilate this region. Following this, multiple images were obtained and showed that there was residual persistent stenosis and

therefore, a 6 x 40 balloon was again used to dilate at high pressure for over 2 1/2 minutes. At this point, the stenosis appeared to be less but there was still a residual stenosis at the AV junction, but this now appeared to be more in the 50% range and it was right at the anastomotic

segment. At this time, there was some irregularity in the outflow, particularly at the needle puncture site, and this site was dilated using a 6 x 100 balloon. The outflow was also dilated using the 6 x 100 balloon to improve flow through the fistula.

At the end of the procedure, there was excellent flow through the graft and both the sheaths were removed a purse-string suture was applied with hemostasis. The right femoral arterial sheath was also removed and hemostasis obtained.

The patient tolerated the procedure well and will be transferred to dialysis in a stable condition.

OVERALL CONCLUSIONS:

1. This was a complex intervention with multiple exchanges as well as multiple passes.

2. Complete thrombosis of the AV graft.

3. High grade inflow stenosis at the arterial to graft anastomosis.

4. Pulse/spray thrombolysis and thrombectomy of the entire graft.

5. Multiple inflations including the inflow, outflow, as well as the graft.

Fistulagram coding assistance needed