36819

Arteriovenous Anastomosis, Open; Upper Arm Basilic Vein Transposition

CPT code 36819 describes a surgical procedure used to create vascular access for hemodialysis in patients with end-stage renal disease (ESRD). This specific procedure involves the creation of an arteriovenous (AV) fistula by surgically mobilizing the basilic vein in the upper arm and transposing it to a more superficial position. The basilic vein is naturally located deep within the medial aspect of the upper arm, making it difficult to access for regular dialysis cannulation. During this open procedure, the surgeon makes a long incision to identify and dissect the basilic vein away from its surrounding tissues and the adjacent brachial nerve and artery. After the vein is sufficiently mobilized, it is typically divided at a distal point or kept intact while being redirected into a subcutaneous tunnel created closer to the skin surface. An anastomosis is then performed, usually connecting the end of the basilic vein to the side of the brachial artery (end-to-side anastomosis). This transposition is critical because it allows the vein to 'mature'—thickening its walls and increasing its diameter due to the high-pressure arterial flow—while remaining accessible for dialysis needles. This procedure is often preferred when the more superficial cephalic vein is unavailable or has failed, as the basilic vein is often well-preserved. It is a more complex undertaking than a standard primary AV fistula (like the Cimino fistula) because of the extensive dissection and the need to relocate the vessel.

Clinical Indications

  • End-stage renal disease (ESRD) requiring long-term hemodialysis access.
  • Inadequate or exhausted superficial venous system (e.g., failed cephalic vein access).
  • Chronic kidney disease (CKD) stage 5 with imminent need for dialysis.
  • Requirement for a high-flow vascular access with lower infection rates compared to prosthetic grafts.
  • Anatomically suitable basilic vein (typically >3mm diameter) as determined by preoperative ultrasound mapping.

Procedure Steps

  1. The patient is placed in a supine position with the arm abducted and externally rotated.
  2. General or regional block anesthesia is administered.
  3. A longitudinal incision is made along the medial aspect of the upper arm to expose the basilic vein.
  4. The basilic vein is carefully dissected and mobilized from the axilla to the antecubital fossa, ligating all side branches.
  5. The brachial artery is identified and isolated at the planned anastomosis site.
  6. A subcutaneous tunnel is created on the anterior/lateral surface of the arm.
  7. The mobilized basilic vein is transposed through the tunnel to its new superficial position, ensuring no kinks or twists.
  8. Systemic heparin may be administered to prevent intraoperative thrombosis.
  9. A small arteriotomy is performed on the brachial artery.
  10. An end-to-side anastomosis is created between the basilic vein and the brachial artery using fine non-absorbable sutures.
  11. Blood flow is restored, and the surgeon confirms the presence of a palpable thrill and audible bruit over the fistula.
  12. The incision is closed in layers, and a sterile dressing is applied.

Coding Guidelines

  • CPT 36819 includes the mobilization and transposition of the basilic vein; do not report vessel harvesting (e.g., 35500) separately.
  • If the procedure is performed as a two-stage operation, use modifier 58 for the second stage if it falls within the global period of the first.
  • Do not report 36819 in conjunction with 36818 (cephalic transposition) or 36821 (direct anastomosis) on the same extremity during the same session.
  • Preoperative vascular mapping (e.g., 93970, 93971) is separately reportable if performed and documented prior to the surgical encounter.
  • Intraoperative radiologic supervision and interpretation may be reported separately if performed (e.g., 74360), though this is uncommon for initial creation.
  • For repair of a previously created fistula, see codes 36831-36833.

Associated ICD-10 Codes