DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. End-stage renal disease.
2. Obesity.
3. Clotted left upper extremity arteriovenous graft.
POSTOPERATIVE DIAGNOSES:
1. End-stage renal disease.
2. Obesity.
3. Clotted left upper extremity arteriovenous graft.
4. Axillary vein stricture.
PROCEDURES PERFORMED:
1. Thrombectomy.
2. Balloon angioplasty.
3. Venogram.
4. Atherectomy.
ANESTHESIA: MAC with local injection of 1% Carbocaine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 25 mL.
SPECIMENS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old obese Hispanic female with end-stage renal disease, who has a left brachioaxillary AV graft, which was found to be clotted yesterday. The patient presents for thrombectomy and possible revision. After discussing the options, benefits, risks and complications, the patient signed the informed consent and was taken to the operating room.
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating room table. After adequate IV access and IV sedation, the patient’s left arm was prepped from the fingertips to the axilla, draped with sterile linen and sterile drapes. The graft was examined and found to be without pulse and without thrill. An area over the venous limb was infiltrated with 1% Carbocaine and incised with a 15 blade scalpel and bluntly and sharply dissected down onto the graft. A vessel loop was placed for control. The graft was opened with an 11 blade scalpel, thrombectomized both arterially and venously.
The intraoperative venogram showed that there was an 8 cm poststented stricture in the axillary vein, which was approximately 2 mm in diameter. The stent was intact and had no thrombus within and no defects. The arterial limb was without defects. The graft was quite thickened, and an atherectomy catheter was now placed in each limb and atherectomized. Each was irrigated with heparinized saline. A 150 cm guidewire was placed across the axillary stricture, and an 8 mm x 8 cm Conquest balloon angioplasty catheter was placed over the wire and across the stricture and inflated to 20 atmospheres serially over 10 minutes. The balloon was repositioned and deployed again. Postdeployment angioplasty was performed 5 minutes after deflation of the balloon. The stricture resolved to 90% of the lumen, measuring just under 7 mm.
The limbs were both irrigated with heparinized saline. The graft was repaired with a double armed 6-0 Prolene suture and flow was reestablished with a thrill within it. The wound was irrigated with Kantrex solution, and the wound was closed in a two-layer fashion with 4-0 PDS suture. The patient tolerated the procedure well and was taken to the same day surgery suite in awake and stable condition.
