Help....Similar to previous IR case posted

Coded as 37278,76937, and 76080

1. Left upper extremity AV graft declot.

2. Left upper extremity AV graft venous anastomosis stent deployment.

3. Fistulogram

Indication: End-stage renal disease, dysfunctional left upper terminating

graft

Comparison: 11/16/2014

Anesthesia: General with ETT per anesthesiology.

Medications:

1% lidocaine local

Heparin 100 units/kg x1

Contrast: 52 mL Omnipaque 350

Fluoro time: 9.9 minutes.

Radiation exposure: 21.22 mgy

Complications: None immediate

TECHNIQUE:

The risks, benefits, and alternatives to the procedure were explained to

the child's mother. Written informed consent was obtained.

The child was placed supine. The left upper extremity was prepped and

draped in usual sterile fashion. Using ultrasound guidance, 21-gauge

needle was used to access the AV dialysis graft aimed towards the venous outflow.

The 0.018 wire was advanced through the needle into the graft, and a 5 French micropuncture introducer set was advanced over the wire. Access was also obtained in a separate location aimed towards the arterial anastomosis with a 21-gauge needle. A 0.018 wire was advanced through the dialysis graft, and a 5 French micropuncture introducer set was advanced over the wire. 2 mg of TPA and 5 mL normal saline was injected through each micro puncture introducer set. The TPA was allowed to dwell in the clotted graft for approximately 15 minutes.

A 0.035 Rosen wire was advanced through the micropuncture introducer set

towards the venous outflow. Venous anastomotic stenosis prevented the

Rosen wire from advancing beyond stenosis. The Rosen wire was exchanged

for a 0.035 Glidewire which was maneuvered beyond the stenosis. A 4 French

Kumpe catheter was advanced over the wire, and the Glidewire was exchanged for Rosen wire. The Kumpe was removed. A 9F 10 cm sheath was advanced over the Rosen wire.

A 0.035 Glidewire was advanced through the micropuncture introducer set

aimed towards the arterial anastomosis. The Glidewire was used two

maneuver beyond the arterial anastomosis and ascend within the brachial

artery. A Kumpe catheter was advanced over this guidewire, and the

Glidewire was exchanged for a 0.035 Rosen wire. A 6 French short 10 cm

sheath was then advanced over the Rosen wire.

A 100 unit per kilogram bolus of Heparin was given. A 6 mm x 4 cm conquest

balloon was advanced through the sheath over the Rosen wire towards the

venous anastomosis. Balloon inflations were performed serially to macerate

the clot. A waist was noted at the venous anastomosis. The waist was

broken with balloon inflation at burst pressure. No other areas of

abnormal wasting were identified.

A 5 French Fogarty catheter was advanced over the Rosen wire beyond the

arterial anastomosis. The balloon was inflated, and pulled through the

anastomosis to remove the thrombus plug near the arterial anastomosis. The

thrombus was pulled back to the level of the sheath aimed towards the

arterial anastomosis. This step was repeated. Then, the 6 mm x 4 cm

conquest balloon was again insufflated serially to macerate the thrombus. Mild residual wasting was seen at the level of the venous anastomosis (approximately 30-40% residual stenosis). The balloons were removed over wire. A fistulogram was performed.

The wire and catheter crossing the arterial anastomosis were removed. Over

the wire, and towards the venous anastomosis, a 7 mm x 5 cm PTFE covered

Bard FLAIR stent was advanced crossing the area of the venous anastomosis.

The stent was deployed, and balloon angioplasty was performed to 7 mm

within the stent. Repeat fistulogram was performed. Ultrasound of the

graft, confirming Doppler flow within the graft, was performed.

The wires and sheaths were removed. Purse string sutures were placed. The

patient tolerated the procedure well without any immediate complications.

Images were stored in PACS.

FINDINGS:

1. Occlusive thrombus throughout the AV graft at the beginning of the

procedure.

2. Sonographically and fluoroscopically normal arterial anastomosis.

3. Mild residual wasting at the venous anastomosis following balloon

angioplasty (approximately 30-40% residual stenosis).

5. Successful deployment of a 7 mm x 5 cm PTFE covered Bard FLAIR

stent with excellent angiographic result (no residual stenosis).

_____________________

IMPRESSION:

1. Successful declot of the patient's left upper extremity AV graft.

2. Technically successful deployment of a covered stent, as above, at

the venous anastomosis with excellent angiographic result.

PLAN:

Once the patient has received 2 to 3 sessions unsuccessful dialysis

through the AV graft, the patient's right internal jugular tunneled

dialysis catheter may be removed in interventional radiology. The patient

is to remain on Aspirin (81 mg daily).

Help....Similar to previous IR case posted