Good Morning,
I am hoping someone could assist me on this report, I am so
TIA.
INDICATIONS: 76 year-old gentleman with end stage renal disease and
a functioning left forearm AV fistula for the last several weeks but
recently they have noticed significant increased venous pressures and
inability to obtain dialysis earlier this morning. He has a native
fistula that is a basilic vein that was looped in the forearm and
anastomosed to the brachial artery just below the antecubital crease.
OPERATIVE DETAIL: Patient was identified in the holding area and
brought back to the Endovascular suite and placed on the table in a
supine position. His left hand was prepped and draped out in a
sterile fashion. The dialysis needles were left in place to
potentially facilitate therapy. Essentially two 16 gauge needles
were placed going in opposite directions in the ulnar side of the
forearm. Through both needles dye was injected. This showed a
basilic vein based fistula in the forearm which was essentially
looped from the ulnar side to the radial side connecting to the
radial artery. The proximal half of the fistula was diffusely
narrowed until the loop where the distal half was nicely patent and
of good size. Percutaneous access was then obtained. We were able
to place a J-wire through the arterial needle in essentially
retrograde access. The 6-French sheath was then placed over this
wire. We needed a glidewire to manipulate through the diffuse
narrowing through the arterial anastomosis into the brachial artery
near the elbow. A 5 mm x 6 cm balloon was chosen. Balloon
angioplasty was performed of the arterial anastomosis as well as the
entire half of the loop graft which was diffusely narrowed.
Prolonged angioplasty at 3 minute insufflations was performed. Final
insufflation at the loop where a very focal high grade stenosis was
noted. Completion fistulogram showed excellent results of the
proximal portion of the fistula. Through the same access site we
looked more proximal in the upper arm as well as the central veins
thus performing a central venogram. In the upper arm patient had a
nicely enlarged basilic vein that could be used for future dialysis.
Cephalic vein was not seen but patency could be possible. The
basilic vein dove nicely into the axillary and subclavian vein which
fed into the central veins without any evidence of stenosis. The
6-French sheath was removed and 3.0 Vicryl u-stitch was placed. The
venous outflow dialysis needle was still in place and this was
removed and 3.0 Vicryl u-stitch was placed. Pressure was held for 10
minutes with good hemostasis. Sterile gauze dressing was placed.
Patient had a nice thrill throughout the fistula without any
complaints of pain or discomfort in his arm. Patient tolerated
procedure well and went to recovery in stable condition.
I am hoping someone could assist me on this report, I am so
TIA.
INDICATIONS: 76 year-old gentleman with end stage renal disease and
a functioning left forearm AV fistula for the last several weeks but
recently they have noticed significant increased venous pressures and
inability to obtain dialysis earlier this morning. He has a native
fistula that is a basilic vein that was looped in the forearm and
anastomosed to the brachial artery just below the antecubital crease.
OPERATIVE DETAIL: Patient was identified in the holding area and
brought back to the Endovascular suite and placed on the table in a
supine position. His left hand was prepped and draped out in a
sterile fashion. The dialysis needles were left in place to
potentially facilitate therapy. Essentially two 16 gauge needles
were placed going in opposite directions in the ulnar side of the
forearm. Through both needles dye was injected. This showed a
basilic vein based fistula in the forearm which was essentially
looped from the ulnar side to the radial side connecting to the
radial artery. The proximal half of the fistula was diffusely
narrowed until the loop where the distal half was nicely patent and
of good size. Percutaneous access was then obtained. We were able
to place a J-wire through the arterial needle in essentially
retrograde access. The 6-French sheath was then placed over this
wire. We needed a glidewire to manipulate through the diffuse
narrowing through the arterial anastomosis into the brachial artery
near the elbow. A 5 mm x 6 cm balloon was chosen. Balloon
angioplasty was performed of the arterial anastomosis as well as the
entire half of the loop graft which was diffusely narrowed.
Prolonged angioplasty at 3 minute insufflations was performed. Final
insufflation at the loop where a very focal high grade stenosis was
noted. Completion fistulogram showed excellent results of the
proximal portion of the fistula. Through the same access site we
looked more proximal in the upper arm as well as the central veins
thus performing a central venogram. In the upper arm patient had a
nicely enlarged basilic vein that could be used for future dialysis.
Cephalic vein was not seen but patency could be possible. The
basilic vein dove nicely into the axillary and subclavian vein which
fed into the central veins without any evidence of stenosis. The
6-French sheath was removed and 3.0 Vicryl u-stitch was placed. The
venous outflow dialysis needle was still in place and this was
removed and 3.0 Vicryl u-stitch was placed. Pressure was held for 10
minutes with good hemostasis. Sterile gauze dressing was placed.
Patient had a nice thrill throughout the fistula without any
complaints of pain or discomfort in his arm. Patient tolerated
procedure well and went to recovery in stable condition.