CPT® Code 35686

Add-On Code

1. Indications

The creation of a distal arteriovenous fistula during lower extremity bypass surgery is indicated in specific clinical scenarios where there is a need to enhance blood flow. The following conditions warrant this procedure:

• Poor outflow from bypass graft: This occurs when the bypass graft does not adequately supply blood to the remaining portion of the native artery, leading to potential complications in limb perfusion.
• Insufficient venous outflow tract: When there is a lack of an effective venous outflow pathway, the fistula can be created to improve blood circulation in the lower extremity.

2. Procedure

The procedure for creating a distal arteriovenous fistula involves several critical steps that ensure the successful establishment of the fistula. Each step is essential for achieving the desired outcome of improved blood flow.

• Step 1: The surgeon begins by identifying the affected artery and the adjacent vein that will be used to create the fistula. This involves careful dissection to free these structures from surrounding tissues, ensuring that they are adequately exposed for the procedure.
• Step 2: Once the artery and vein are dissected, the surgeon ligates the branches of the vein. This step is crucial as it prevents blood flow through these branches, directing it instead through the newly created fistula.
• Step 3: The distal end of the vein that is being utilized for the fistula is also ligated. This action is necessary to prepare the vein for anastomosis and to ensure that blood flow is redirected appropriately.
• Step 4: The next step involves making an incision in the native vein. This incision allows for the connection of the modified venous bypass graft.
• Step 5: The surgeon then performs an anastomosis, connecting the modified venous bypass graft to both the native artery and the native vein. This connection creates the distal arteriovenous fistula, facilitating improved blood flow from the bypass graft to the lower extremity artery.

3. Post-Procedure

After the creation of the distal arteriovenous fistula, post-procedure care is essential to ensure proper healing and function of the fistula. Patients are typically monitored for any signs of complications, such as bleeding or infection at the surgical site. Additionally, the effectiveness of the fistula in improving blood flow is assessed during follow-up visits. Patients may be advised on activity restrictions and signs to watch for that could indicate issues with the fistula. Overall, the recovery process is closely managed to promote optimal outcomes following the procedure.