36818

Arteriovenous anastomosis, open; by vein transposition

CPT code 36818 describes an open surgical procedure to create an arteriovenous (AV) fistula for hemodialysis access, specifically by means of vein transposition. In this procedure, a native superficial vein (e.g., basilic or cephalic vein) is dissected, mobilized from its anatomical position, and transposed (relocated) to a deeper or more proximal arterial inflow (e.g., brachial artery). The transposed vein is then surgically anastomosed (connected) to the artery. This technique is typically employed when the native vein in its original location is unsuitable for direct AV fistula creation due to its small caliber, deep anatomical position, or extensive scarring, requiring relocation to achieve adequate flow, maturation, and accessibility for cannulation for long-term hemodialysis.

Clinical Indications

  • End-stage renal disease (ESRD) requiring chronic hemodialysis and necessitating permanent vascular access.
  • Unsuitability of superficial veins in their native anatomical position for direct arteriovenous fistula creation due to factors such as small diameter, deep location, extensive scarring from prior interventions, or a history of multiple failed previous access attempts.
  • Requirement for a durable and high-flow vascular access in patients with limited suitable vein options.
  • Revision or creation of new vascular access following complications or failure of a previously established arteriovenous fistula or graft.
  • Poor superficial vein quality or location that precludes successful cannulation and maturation of a direct AV fistula.

Procedure Steps

  1. Patient positioning and sterile preparation of the chosen extremity (typically arm).
  2. Incision made to expose the target artery (e.g., brachial, radial, ulnar) and the selected native vein (e.g., basilic, cephalic).
  3. Careful dissection and mobilization of the native vein, preserving critical branches and ensuring adequate length for transposition.
  4. Ligation of any necessary venous tributaries to isolate the main vein segment.
  5. Creation of a subcutaneous tunnel or new anatomical path for the vein to be transposed, allowing it to lie more superficially or closer to the target artery.
  6. Transposition of the mobilized vein through the prepared tunnel or path to its new anatomical position.
  7. Preparation of the artery and vein for anastomosis, including arteriotomy and venotomy.
  8. Surgical anastomosis (connection) of the transposed vein to the artery, typically in an end-to-side or side-to-side fashion, using appropriate suturing techniques.
  9. Confirmation of thrill and patency of the newly created arteriovenous fistula.
  10. Achievement of hemostasis and layered closure of the surgical incisions.

Coding Guidelines

  • CPT code 36818 is subject to a 90-day global surgical period.
  • This code specifically applies to open arteriovenous anastomosis created by *vein transposition*. It is distinct from direct AV fistula creation (36817) or AV fistula creation by saphenous vein transposition (36819).
  • The operative report must clearly document the specific artery and vein used, the technique of vein transposition, and confirmation of fistula patency.
  • Related services, such as exploration of vessels, creation of a subcutaneous tunnel, and simple closure, are considered integral components of the procedure and are not separately reportable.
  • Modifier 50 (Bilateral Procedure) would rarely apply as AV fistulas are typically created unilaterally. If a distinct AV fistula is created in both arms on the same day, modifier 50 or separate reporting with modifier 59 (Distinct Procedural Service) may be considered with strong clinical justification, though highly uncommon for this specific procedure.
  • Do not unbundle components of the AV fistula creation, such as venectomy or arterial repair if performed as part of the primary procedure.

Associated ICD-10 Codes