With the patient in the supine position, general
anesthesia was accomplished by anesthesia services. The left arm was
prepped and draped in the usual sterile fashion. The patient was noticed
preoperatively to have a slight erythematous area just proximal to the
antecubital space at the inflow of her graft, as such the approach to the
graft operatively was then selected to be more distal to avoid the
erythematous area. Therefore, approximately 4 cm from the graft/venous
anastomosis, 1% Xylocaine without epinephrine was used to obtain local
anesthesia, and then an approximately 3 cm transverse incision was made
over the graft. The graft was identified, freed from surrounding tissue,
and mobilized proximally and distally. The patient was then anticoagulated
systemically with 4000 units of heparin. A transverse graftotomy was made
and multiple passages of the 4-French Fogarty catheter were made proximally
in the graft toward the venous outflow in an incremental fashion clearing
the graft of retained thrombus with each pass. Eventually, the Fogarty
catheter was advanced across the anastomosis into the venous outflow, and
the anastomosis was widely opened with passage of the catheter. Back
bleeding was then controlled with direct pressure over the anastomosis.
Several additional passes with the catheter were made until eventually no
more thrombus was retrieved. A #6 French Pinnacle was then introduced into
the distal aspect of the graft and an angiogram was accomplished. Multiple
views were obtained. There was good outflow from the graft, but several
views suggested a slight jet phenomenon of the contrast. Therefore, a
Glidewire was passed under fluoroscopic guidance across the anastomosis and
a 6 mm diameter 4 cm length angioplasty balloon was passed across the
anastomosis and inflated to 10 atmospheres. No waist was appreciated.
Multiple additional balloon inflations were accomplished; all of 1 minute
duration. Repeat angiogram of the outflow of the graft noted no evidence of
a stenotic process and good flow of contrast material. The distal graft was
flushed with heparinized saline and clamped.
Attention was then turned to the proximal portion of the graft, where again
incremental passage of the 4-French Fogarty catheter was accomplished until
just distal to the arterial anastomosis. At this point, a 3-French Fogarty
catheter was placed across the anastomosis, and the anastomosis was cleared
of the arterial plug without difficulty, and in fact the inflow was strong
enough to force the arterial plug out of the graftotomy and onto the field.
Inflow control was obtained with direct pressure. Multiple additional
passes of the catheter were obtained to ensure that the anastomosis was
widely patent and a good inflow was obtained. The proximal graft was then
irrigated with heparinized saline and clamped. The graftotomy was then
closed with a running 6-0 Prolene suture without difficulty. Flow was
reestablished to the graft, and there was an obvious and very apparent
proximal thrill extending up through the graft into the venous outflow. The
wound was irrigated out with normal saline. Hemostasis was verified, and
then the wound was closed in 2 layers with 3-0 Polysorb suture closing the
dermal layer and a running intracuticular 4-0 Caprosyn suture closing the
skin. The wound was cleaned. A Steri-Strip was applied. A dressing was
applied, and the procedure was terminated.
Any and all help is appreciated!
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Fistula thrombectomy, fistulogram, and balloon angioplasty