PREOPERATIVE DIAGNOSIS: 56-year-old male with end-stage renal disease
POSTOPERATIVE DIAGNOSIS: End-stage renal disease
PROCEDURE PERFORMED: Right arm arteriovenous graft
ANESTHESIA: iNTRAVENOUS SEDATION WITH LOCAL
Fluids: 500 cc
ESTIMATED BLOOD LOSS: Minimal
DESCRIPTION OF PROCEDURE: Patient came to the operating room and was placed on the operating
table. After IV was placed and patient was given IV sedation, the right arm from the axilla down to the
wrist was prepped and draped in the standard surgical fashion. Attention was turned to the veins in the
forearm. Dissection was made of the patient’s antecubital fossa, at which time the brachial artery was
located. The cephalic vein was also located, and another incision was made 2 cm proximal to the
patient’s wrist. When these vessels were isolated, a tunnel was placed in the subcutaneous tissue from
the antecubital fossa to the wrist in a circular fashion. At this point, the PTFE graft was brought on to
the table. Approximately 6 mm diameter of PTFE graft was used. The graft was sutured into the vein,
and then the graft was brought through the subcutaneous tunnel ensuring that there was enough skin
to cover the distal portion of the graft as it made its turn in the subcutaneous tissue. The graft was then
sutured to the artery. Upon release of the vessel clamp, a bruit was appreciated, and a thrill was felt in
the graft. Patient tolerated the procedure well.
* what is the CPT code for this scenario?
DISPOSITION: To the PACU and then to be discharged home in stable condition.
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