PREOPERATIVE DIAGNOSIS: 56-year-old male with end-stage renal disease POSTOPERATIVE DIAGNOSIS: End-stage renal disease PROCEDURE PERFORMED: Right arm…

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

SPECIMENS:  None

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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