Over the years I've come across several instances of steal, with significant forearm artery disease.  With high flow fistulae, usually we have reasonable results with banding.

The more challenging cases seem to be the lower flow fistulae, especially those with calcified forearm arteries.  We usually refer these for a DRIL/ proximalization of arterial inflow. 

The patient here presented with an ulceration at his 5^th finger, consistent with distribution of flow from the ulnar artery.  Here, it appeared that the culprit was steal with the presence of a calcified ulnar artery.

I generally approach these cases with a full arteriogram, and address any clear, focal lesions with angioplasty.  However, I have been somewhat reluctant to pursue diffuse arterial calcification – with concerns for spasm/ trauma with angioplasty of extremely small vessels. 

Just wanted to see what some of your experiences are with these type of small arterial vessel issues.  Is anyone using arthrectomy on these types of cases?  Do any of you stent these lesions or pursue attempts at angioplasty with diffuse vascular disease?

Forearm arterial calcification seems similar to lower extremity peripheral arterial disease –and there have been significant advances with endovascular arterial arthrectomy and treatment of limb ischemia.  Are any of you employing these techniques in forearm arteries?

Danny Patel

[ 7/10/2017:  ADDED IMAGES FROM DR. POURCHEZ]

Original Coding Alert from 12/27/2016 is attached for reference.

Q:  

In regard to the Coding Alert from 12/27/16 on moderate sedation claims, can you tell me if this has been corrected and if I should go ahead and rebill or appeal these sedation codes? I called Medicare today (4/12) and they didn’t seem to know anything about this. 

A:  The new NCCI procedure to procedure edits did come out April 1 so it makes sense to resubmit claims, though carriers sometimes lag behind. Apparently, some intermediaries have been able to make corrections internally and are paying the codes for sedations.  Other intermediaries are not able to make the corrections internally and are having to wait until Medicare makes them.   For this reason, some are now paying and some are not.  Probably will be some variability in local carriers for a while.

I had had an interesting PD case today that I thought I would share, as this is the 

first time I have seen this.

I was sent a patient with a laparoscopically placed right sided double cuffed

coilec PD  cather with midline infra-umbilical approach about 5 weeks prior with

intra-Peritoneal fixation. He was sent for complete outflow failure and 

inflow with some resistance.

We initially flushed and aspirated a few fibrin plugs from the 

catheter - we did not manipulate the PD catheter with wire or 

styler. On PD gram I see what I think is encasemrnt of the coil

and I think separation of the catheter with injection. (Video link included)

my suspicion is that the catheter might have torn perhaps by 

coming in contact with the staples then completly separated on 

contact injection.

the pt will see the surgeon for Laparoendoscopic replacement.

i am interested in knowing if others have seen this and their thoughts.

Raj.

This patient presented to us for an AVF creation. He was getting hemodialysis through a temporary jugular catheter ( which was there in position for a month and a half !!). We were planning for a tunnelled line placement followed by an AVF creation. As per our protocol we did a venogram before creating the AVF. There was stasis of dye around the central venous area. Contrast injected through the temporary catheter as a part of the venogram showed an ? SVC thrombus surrounding the catheter. ECHO ruled out any RA thrombus.

Now i don't know if

     a) I have to remove the catheter or to keep it insitu

     b) Convert this temporary line to a tunnelled line ( with a possible risk of embolization during the procedure)

     c) Create an AVF ( with a possible risk of immaturity/failure secondary to a compromised central vasculature)

I don't know how much of my fears are real..expecting inputs from the experts..

 Please use the youtube link above for the video.

Dr Venkatesh Rajkumar,

Chennai,

India.

Recently I have had several patients with a fairly new catheter (1-2months old) who presented with fairly sudden onset of pain and redness extending up the neck over the internal jugular vein. they had no fever or infectious symptoms and the catheter was functioning well. The catheter tunnel and exit site were normal. We drew blood cultures and gave empiric antibiotics - and then the blood cultures returned negative. I think the symptoms are a result of thrombophlebitis because of the relatively acute thrombosis. The symptoms improve with 3-5 days of NSAID.

My question is whether anticoagulation is required or appropriate in this setting? Would you use Lovenox and/or Warfarin? For how long?

Thanks,

Tim Pflederer

*Image to follow

An issue I've come across a few times but honestly have only relied on standard and drug-coated balloons for my intervention has been the refractory anastomotic stenoses at a terminal artery.  By this, I mean either a Radial-Cephalic AVF where the Radial Artery distal to the AVF is completely occluded (and thus all flow to the hand is via the Ulnar Artery, with the Radial Artery essentially merely supporting flow to the AVF itself), or in an upper arm AVF where the surgeon inadvertently vs intentionally used a High-Takeoff Radial Artery for the inflow and again the artery distal to the anastomosis becomes quite atretic, thereby leaving the Brachial/Ulnar to supply the forearm/hand.  I have not seen lasting (and honestly nor did I expect) results from either standard/DCB's of the arterial anastomosis.

Today was another such example.  Aside from sending the patient back to surgery to move the arterial anastomosis more proximal, have any of you simply stented this region into the artery itself since the atretic segment of the artery distal to the anastomosis is essentially non-functional anyway (provided you have first documented adequate flow to the Palmar Arch via another vessel)?

As you can see from the (soon to be uploaded) picture, I'd hate to lose such an otherwise nice AVF during a proximalization of the arterial anastomosis.  However, we're also talking about already small vessels here, so would a 5mm Viabahn vs other stent actually provide enough increased vascular lumen to make a difference?

Regards,

Kevin Harned, MD