PREOPERATIVE DIAGNOSES:
Thrombosis dialysis access
ESRD
DM II
Hypertension
Hyperlipidemia
Chronic anemia
POSTOPERATIVE DIAGNOSES:
Thrombosis dialysis access
ESRD
DM II
Hypertension
Hyperlipidemia
Chronic anemia
PROCEDURES:
Thrombectomy right brachiocephalic fistula.
Operative fistulogram.
Angioplasty cephalic arch and venous limb 8,10 mm.
Angioplasty brachiocephalic vein 10 mm
Plication venous limb aneurysm
Segmental resection venous limb
End-end anastomosis
Deployment 7 mm x 5 cm Viahbahn stent in the cephalic arch
Angioplasty Viabahn stent 7 mm
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
150 ml.
FLUIDS:
400 ml NS and 450 ml NS
DRAINS:
None.
SPONGE COUNT:
Correct.
PATIENT STATUS:
Stable.
INDICATIONS:
This is a 63 y.o. black male who has a thrombosed dialysis access and presents for access thrombectomy.
DESCRIPTION OF FINDINGS:
The patient had a high grade resistant cephalic arch stenosis and a stenosis between the mid fistula and venous limb aneurysms with abundant intimal hyperplasia.
SUMMARY:
After placement of the patient in the supine position and satisfactory induction with general endotracheal anesthesia, the arm was placed out on an arm board, prepared with Betadine scrub and Betadine paint, and draped with towels and sheets in a standard sterile fashion. A transverse incision was made over the arterial limb with a knife and the subcutaneous tissues were opened with electrocautery. The fistula was mobilized proximally and distally and looped with a vessel tape. A transverse fistulotomy was made. A # 8 was passed multiple times up the venous limb of the access, retrieving thrombus. The fistula was massaged to loosen clot from the wall of the fistula. When no further thrombus was being retrieved, the patient received 5000 units of heparin systemically. The venous limb was clamped and a # 8 embolectomy catheter was passed up into the arterial limb, retrieving thrombus. The fistula was massaged to loosen clot from the wall of the fistula. When no further clot was being retrieved, a 9 French introducer was placed into the venous limb and an outflow fistulogram revealed a venous limb stenosis between the mid fistula and venous limb aneurysms. There was a high grade cephalic arch stenosis at the insertion into the subclavian vein. A 0.35 guidewire was passed through the introducer followed by a 8 mm angioplasty balloon. This was inflated in the cephalic arch and venous limb in tandem to 20 atmospheres. A repeat fistulagram revealed persistent stenosis. The balloon was deflated and removed. The venous limb was flushed with heparinized saline, the introducer was removed and the venous limb was clamped. The 9 French introducer was placed into the inflow and an inflow fistulogram revealed no stenosis. A 0.35 guidewire was passed through the introducer into the venous limb. A 10 mm angioplasty balloon was passed over the wire and inflated in the areas of stenoses. A repeat fistulagram revealed filling irregularities in the venous limb stenosis and a persistent high grade stenosis of the cephalic arch. A vertical incision was made over the venous limb aneurysm. The fistula was mobilized circumferentially. The fistula was clamped proximally and distally and a segment of the fistula was excised. It was filled with pseudointimal hyperplasia. The ends were spatulated and sewn in an end-end fashion using running 6-0 Prolene sutures. The top of the aneurysm was excised and the fistula was closed vertically with a running 6-0 Prolene suture. Clamps were released. The arterial limb fistulotomy was closed. There were pulsations in the access. The arterial limb was clamped. The sutureline in the arterial limb was removed. A 9 F introducer was passed into the venous limb. A .035 guidewire was passed followed by a 7 mm x 5 cm Viabahn stent. This was deployed in the cephalic arch at the high grade stenosis. The stent was angioplastied with a 7 mm angioplasty balloon. A 10 mm angioplasty balloon was passed into the brachiocephalic vein and angioplastied to 14 atmospheres. A repeat fistulagram revealed improved caliber of the fistula. The fistulotomy was again closed with a running 6-0 Prolene suture. Vascular clamps were released. There were softer pulsations in the access. The subcutaneous tissues were closed with interrupted 3-0 Vicryl sutures and the skin was closed with a running subcuticular 5-0 Maxon suture. Benzoin and Steri-Strips were applied, followed by sterile gauze and Tegaderm dressings. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.
Thrombosis dialysis access
ESRD
DM II
Hypertension
Hyperlipidemia
Chronic anemia
POSTOPERATIVE DIAGNOSES:
Thrombosis dialysis access
ESRD
DM II
Hypertension
Hyperlipidemia
Chronic anemia
PROCEDURES:
Thrombectomy right brachiocephalic fistula.
Operative fistulogram.
Angioplasty cephalic arch and venous limb 8,10 mm.
Angioplasty brachiocephalic vein 10 mm
Plication venous limb aneurysm
Segmental resection venous limb
End-end anastomosis
Deployment 7 mm x 5 cm Viahbahn stent in the cephalic arch
Angioplasty Viabahn stent 7 mm
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
150 ml.
FLUIDS:
400 ml NS and 450 ml NS
DRAINS:
None.
SPONGE COUNT:
Correct.
PATIENT STATUS:
Stable.
INDICATIONS:
This is a 63 y.o. black male who has a thrombosed dialysis access and presents for access thrombectomy.
DESCRIPTION OF FINDINGS:
The patient had a high grade resistant cephalic arch stenosis and a stenosis between the mid fistula and venous limb aneurysms with abundant intimal hyperplasia.
SUMMARY:
After placement of the patient in the supine position and satisfactory induction with general endotracheal anesthesia, the arm was placed out on an arm board, prepared with Betadine scrub and Betadine paint, and draped with towels and sheets in a standard sterile fashion. A transverse incision was made over the arterial limb with a knife and the subcutaneous tissues were opened with electrocautery. The fistula was mobilized proximally and distally and looped with a vessel tape. A transverse fistulotomy was made. A # 8 was passed multiple times up the venous limb of the access, retrieving thrombus. The fistula was massaged to loosen clot from the wall of the fistula. When no further thrombus was being retrieved, the patient received 5000 units of heparin systemically. The venous limb was clamped and a # 8 embolectomy catheter was passed up into the arterial limb, retrieving thrombus. The fistula was massaged to loosen clot from the wall of the fistula. When no further clot was being retrieved, a 9 French introducer was placed into the venous limb and an outflow fistulogram revealed a venous limb stenosis between the mid fistula and venous limb aneurysms. There was a high grade cephalic arch stenosis at the insertion into the subclavian vein. A 0.35 guidewire was passed through the introducer followed by a 8 mm angioplasty balloon. This was inflated in the cephalic arch and venous limb in tandem to 20 atmospheres. A repeat fistulagram revealed persistent stenosis. The balloon was deflated and removed. The venous limb was flushed with heparinized saline, the introducer was removed and the venous limb was clamped. The 9 French introducer was placed into the inflow and an inflow fistulogram revealed no stenosis. A 0.35 guidewire was passed through the introducer into the venous limb. A 10 mm angioplasty balloon was passed over the wire and inflated in the areas of stenoses. A repeat fistulagram revealed filling irregularities in the venous limb stenosis and a persistent high grade stenosis of the cephalic arch. A vertical incision was made over the venous limb aneurysm. The fistula was mobilized circumferentially. The fistula was clamped proximally and distally and a segment of the fistula was excised. It was filled with pseudointimal hyperplasia. The ends were spatulated and sewn in an end-end fashion using running 6-0 Prolene sutures. The top of the aneurysm was excised and the fistula was closed vertically with a running 6-0 Prolene suture. Clamps were released. The arterial limb fistulotomy was closed. There were pulsations in the access. The arterial limb was clamped. The sutureline in the arterial limb was removed. A 9 F introducer was passed into the venous limb. A .035 guidewire was passed followed by a 7 mm x 5 cm Viabahn stent. This was deployed in the cephalic arch at the high grade stenosis. The stent was angioplastied with a 7 mm angioplasty balloon. A 10 mm angioplasty balloon was passed into the brachiocephalic vein and angioplastied to 14 atmospheres. A repeat fistulagram revealed improved caliber of the fistula. The fistulotomy was again closed with a running 6-0 Prolene suture. Vascular clamps were released. There were softer pulsations in the access. The subcutaneous tissues were closed with interrupted 3-0 Vicryl sutures and the skin was closed with a running subcuticular 5-0 Maxon suture. Benzoin and Steri-Strips were applied, followed by sterile gauze and Tegaderm dressings. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.