Arteriovenous Fistula Creation (Hemodialysis Access)

CPT 36821
Approach Open
Add-on / Variant CPTs
  • 36830 — Creation of AV fistula by other than direct arteriovenous anastomosis (prosthetic graft)
  • 36818 — AV anastomosis, open; transposed forearm vein to forearm artery
Preoperative Diagnosis:

End-stage renal disease requiring permanent hemodialysis access

Postoperative Diagnosis:

Same

Procedure Performed:

Left [right] [radiocephalic / brachiocephalic / brachiobasilic] arteriovenous fistula creation

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

Local — [X] mL 1% lidocaine without epinephrine [/ regional brachial plexus block / MAC]

Indications:

The patient is a [age]-year-old [male/female] with end-stage renal disease requiring permanent hemodialysis access. Pre-operative vein mapping demonstrated [cephalic / basilic] vein diameter of [X mm] and [radial / brachial] artery inflow. A [radiocephalic / brachiocephalic / brachiobasilic] AVF was selected. The risks, benefits, and alternatives including AV graft were discussed and informed consent was obtained.

Findings:

The [cephalic / basilic] vein was identified and mobilized with adequate diameter [X mm] and quality. The [radial / brachial] artery was well-pulsatile. The anastomosis was constructed without tension. A thrill was palpable and bruit auscultated throughout the [forearm / upper arm] fistula upon completion.

Description of Procedure:

The patient was positioned supine with the ipsilateral arm extended on an arm board. The [wrist / antecubital fossa] was prepped and draped. Local anesthesia was infiltrated.

A longitudinal incision was made over the [radial artery at the wrist / brachial artery at the antecubital fossa]. The [cephalic / basilic] vein was identified, mobilized for [X] cm, and branches ligated. The artery was dissected and controlled.

The vein was spatulated to match the arteriotomy. A longitudinal arteriotomy [approximately 1 cm] was made. The end-to-side anastomosis was constructed using running [6-0 Prolene] suture. Clamps were released. A thrill was immediately palpable and a bruit audible throughout the fistula. Doppler confirmed flow.

The wound was closed in layers. A light dressing [not circumferentially compressive] was applied.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The patient tolerated the procedure well. A thrill was confirmed at the anastomosis. The patient was instructed on fistula care and to return for fistula maturation assessment in [6–8 weeks]. Dialysis should be initiated through the fistula no sooner than 4–6 weeks post-operatively.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: ESRD — hemodialysis access needed
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** AVF creation
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local — *** mL 1% lidocaine

INDICATIONS: .PTAGE-year-old .PTSEX with ESRD. Vein mapping: *** mm cephalic/basilic, *** artery inflow. Consent obtained.

FINDINGS: Vein *** mm, adequate quality. Artery well-pulsatile. Thrill and bruit confirmed post-anastomosis.

PROCEDURE:
Supine, arm extended on arm board. *** prepped and draped. Local anesthesia infiltrated. *** incision. Cephalic/basilic vein mobilized *** cm, branches ligated. Artery dissected and controlled. Vein spatulated. *** cm arteriotomy. End-to-side anastomosis with running 6-0 Prolene. Clamps released — thrill palpable, bruit audible, Doppler confirmed. Wound closed in layers, light dressing.

EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Thrill confirmed. Maturation assessment in 6–8 weeks. No cannulation for 4–6 weeks.

Signed: .ME, .MYDEGREE
.TODAY
Variants

AV Graft (Prosthetic — Vein Unsuitable)

Given inadequate vein caliber [<2.5 mm] on pre-operative mapping, a prosthetic AV graft was used. A [6 mm] PTFE loop graft was tunneled in the [forearm / upper arm] in a [loop / straight] configuration. Proximal anastomosis was constructed end-to-side to the [brachial / radial] artery and distal anastomosis end-to-side to the [brachiobasilic / antecubital] vein. Thrill was confirmed throughout the graft. AV grafts can be cannulated earlier than AVF (2–3 weeks) but have lower long-term patency.

Brachiobasilic AVF with Transposition

The basilic vein in the medial upper arm was exposed through a longitudinal incision, mobilized from elbow to axilla, ligated and divided distally. The vein was transposed through a subcutaneous tunnel to the lateral arm surface to allow dialysis cannulation access. The proximal end was anastomosed end-to-side to the brachial artery. Thrill confirmed throughout. The transposed vein is typically deeper and smaller diameter than cephalic vein and may require 8–12 weeks for maturation.

Charting Tips
  • Document that a thrill is palpable and bruit is audible at the end of the case. Absent thrill immediately post-operatively indicates technical failure and should prompt intraoperative revision rather than post-operative discovery.
  • Record vein diameter and artery caliber from pre-operative duplex mapping in the note. The 'rule of 6s' for AVF maturation requires vein diameter ≥6 mm, depth ≤6 mm, and length ≥6 cm. Documenting pre-op measurements establishes the expected maturation potential.
  • Document the no-compression dressing instruction and timeline for fistula use. Premature cannulation and inadvertent compression are the two most preventable causes of early fistula failure.
Billing Tips
  • 36821 (direct AV anastomosis any site, 11.60 wRVU) is used for radiocephalic (Brescia-Cimino) fistula at the wrist, which is the most common primary access.
  • Upper arm fistulas: 36818 (brachiocephalic, 12.08 wRVU), 36819 (brachiobasilic transposition, 12.96 wRVU), 36820 (forearm vein transposition, 12.74 wRVU). Document the specific vein used and whether transposition was required.
  • Prosthetic AV graft: 36830 (nonautograft loop or straight, 11.73 wRVU); autogenous conduit graft: 36825 (13.82 wRVU). Document graft material (ePTFE, Dacron, saphenous vein conduit).
  • Global period is 90 days. Post-op fistula mapping, ultrasound surveillance, and routine follow-up within 90 days are bundled. Fistulogram and angioplasty for stenosis use modifier -79 (unrelated) after the global or -78 (complication) within the global.
  • ESRD Network reporting: for Medicare patients on dialysis, document that the patient has ESRD and this is a dialysis access creation. This is required for CMS ESRD quality metrics.
  • Ligation of side branches (accessory vein coil or ligation) performed at the same session is bundled. Do not bill separately.
  • Document: vessel selected (radial/brachial artery, cephalic/basilic/brachial vein), anastomosis configuration, venous diameter on pre-op mapping, thrill/bruit at end of case, and estimated maturation timeline.