September 2017 Q & A

Question: Limbs AV Fistula Declot & Stenting Failure; TPA and Repeat Stent for Extravasation

AV left forearm graft fistulogram showed extensive thrombus in main draining vein up to the level of the distal third of the humerus. Crossing sheaths placed. Angiojet catheter used to treat arterial and venous anastamosis. It worked for arterial but not venous. Angioplasty of arterial anastomosis, with arterial flow re-established. Stent was placed across venous anastamosis to improve outflow. Patient continued to clot despite administration of 10,000 units of heparin during the procedure. Multiple passes again made with the angiojet. Flow was not re-established.

The decision made to initiate TPA therapy for 2 hours with an endhole catheter tip at the arterial anastamosis. After 2 hours, imaging demonstrated extravasation from two thirds of the graft. This was treated with an 8 cm fluency stent overlapping the previously placed Viabahn stent. The stent was balloon dilated to 6 mm. Extravasation ceased, arterial flow could not be established despite multiple maneuvers. Decision made to terminate procedure. Code with 36906 or 36906 & 36903-59 or 36906 & 36906-58?


This would all be coded with 36906 only. All stents placed in the peripheral zone are included, which is the case here.