Thrombectomy help

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I am gathering he did thrombectomy of the arteries and veins.

TIA

PREOPERATIVE DIAGNOSIS:

Clotted, failing right groin loop PTFE.

POSTOPERATIVE DIAGNOSIS:

Clotted, failing right groin loop PTFE.

PROCEDURE PERFORMED:

Declot right groin loop PTFE stent with 157 mm x 150 mm

covered stent and angioplasty with 6 x 100 mm balloon,

thrombectomy right popliteal artery, thrombectomy right

posterior tibial artery and thrombectomy right anterior tibial

artery, tPA thrombolysis right anterior tibial artery, and

left femoral central line placement.

INDICATIONS:

The patient is a very well known 34-year-old dialysis patient

who was on his probably last access and it is failing. I was

asked to evaluate it. They were concerned it was going to

clot and in fact, before he got here today, it did clot. They

have been having poor flow issues. I discussed with Johnny

and his family the risks, benefits, alternatives of the

procedure and informed consent was obtained.

PROCEDURES:

He was placed in the supine position, prepped and draped in a

standard sterile fashion as nobody could get venous access on

him. I placed a left femoral central line and gave him Versed

and Dilaudid for sedation. I then infiltrated lidocaine

overlying the lateral loop of the graft and attempted to

access it as there was no flow in this; it was basically a

blind access. I was able to draw back some blood. Eventually

I did get a little bit of flow as I advanced this catheter and

then I took an angiogram and unfortunately, I had pushed some

clot into the common femoral artery from the graft itself. At

this point, I went ahead and accessed the left common femoral

artery percutaneously and placed a sheath and then I used an

Omniflush catheter to perform aortogram with iliofemoral

runoff. He had very interesting aortic anatomy with 2

bifurcations. I got up and over using the Omniflush and the

Glidewire, had a lot of trouble getting a Destination sheath

up and over, had to use some multipurpose catheter as well as

a wire and the sheath to finally get this over and placed the

Destination sheath in the common femoral artery. I then ran

the right leg; this clot had pushed down to the popliteal

artery just at the tibio-peroneal trunk, so we used the

Angiojet device and performed multiple passes with the

Angiojet in the popliteal artery and that was successful at

opening this up; however, the clot pushed distally into the

anterior tibial and posterior tibial artery. I then advanced

an 0.014 guidewire into the posterior tibial first and then

the anterior tibial and was able to clear the posterior tibial

completely of clot. The anterior tibial I was able to clear

to about the distal calf and this reconstituted via peroneal

collaterals. The peroneal did not ever demonstrate flow. I

then placed a straight catheter into the anterior tibial

artery, injected 2 mg of tPA in hopes that this very distal

clot would dissolve. The patient was awake and 2 hours into

this, he was still asymptomatic in the leg. I then turned my

attention towards the graft itself, I then backed out my

equipment, advanced the guidewire into the graft, cannulated

it all the way into the vena cava and performed Angiojet

thrombolysis on the PTFE graft itself and was able to regain

flow. He had a very diseased graft at the apex of the graft

for a distance of about 180 cm. I placed a covered stent

measuring 7 mm across the apex of this graft to try and open

up the flow and there was still very significant disease

proximal to this. I selected a 6 mm balloon with a prolonged

insufflation here and this improved, but did not completely

resolve the stenosis. I did not want to place the stent

across the entire length of the graft due to concern for

access at a later date. He did have excellent flow and at the

end of this, the sheath that I had placed initially into the

graft itself was removed and I placed a silk stitch there. I

then showed a sheathogram in the left groin, I felt the artery

was too small caliber to close. So we pulled the catheter and

held pressure. Complication was embolus to the femoral and

popliteal arteries as well as a distal infrapopliteal

arteries; this was resolved with thrombolysis. He seemed to

tolerate the procedure well. He will be admitted to the

hospital rather than sent home today and I have notified the

nephrology service.

Thrombectomy help