Treatment strategies of arterial steal after arteriovenous access

Abstract

Steal syndrome after construction of an arteriovenous access for hemodialysis is a rare but potentially devastating complication. When this occurs within the 90-day global period after creation of the graft or fistula, it is considered a “related” procedure. Subsequent therapy as detailed below would require use of the −78 modifier for reimbursement from the insurance carrier. If the intervention occurs more than 90 days after creation, no modifier is typically required unless the patient is within another postoperative global period from an “unrelated” procedure. In the latter situation, appending the −79 modifier would be appropriate. The most straightforward treatment of steal syndrome is ablation of the reconstruction. Ligation of an arteriovenous access is reported by CPT code 37607 (Ligation or banding of angioaccess arteriovenous fistula) and the Centers for Medicare and Medicaid Services has assigned it a 90-day global period. This code description is applicable for use on either a prosthetic graft or an autogenous circuit. It is important to differentiate complete obliteration of the access from CPT code 36832 [Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)] which is proper for ligation of fistula side branches in a separate setting. The latter procedure is performed in an attempt to promote maturation of an already-created autogenous access in a completely different clinical scenario. Efforts to limit flow through the access can be attempted by surgical narrowing of the conduit near the arterial anastomosis. This is termed “banding” and is also reported by CPT code 37607. Suture plication and compression with a piece of prosthetic material placed circumferentially near the arterial anastomosis are both typical examples of such an intervention. To maintain patency of an autogenous access while helping with limb salvage, the distal revascularization and interval ligation procedure may be employed, which includes division of the brachial artery, vein harvest from either the leg or the arm, and a remote brachial artery bypass. CPT code 36838 [Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome)] describes such an intervention in the upper extremity. There is no difference based on whether the arm reconstruction terminates on the brachial, radial, interosseous, or ulnar artery. Also, conduit for the brachial bypass may be autogenous or prosthetic. This single CPT code encompasses all portions of the procedure in the upper extremity. If an analogous surgery is completed in the lower extremity, individual CPT codes for extremity artery ligation and arterial bypass would be reported. Revision using distal inflow (RUDI) and proximalization of arterial inflow (PAI) are both examples of arteriovenous access revision. CPT code 36832 describes revision of an arteriovenous access without thrombectomy. Use of this description is also appropriate for venous outflow patch angioplasty, distal jump grafting, or the second stage of a “two-stage” basilic vein transposition.