AV fistulagram and central venoplasty technique and dictation

Procedure:  

AV graft contrast evaluation

Balloon dilatation at venous anastomosis

Indication: Arm swelling. Chest wall collaterals.

Operators:  

Medications:     mgs IV Versed,     mcg IV fentanyl,      units IV heparin

Contrast:      mL  nonionic  

Fluoroscopy time:     minutes

Access site:  7 F sheath antegrade with ultrasound 

Balloons:      mm x 4 cm Conquest

Complications:  None significant.

Technique:

The risks, benefits, and alternatives to the procedure and sedation were explained to the patient.  The specific risks of bleeding, vascular damage including graft occlusion and arterial embolization/pulmonary emboli were detailed and accepted.  Written informed consent was obtained.  A time out/call to order was performed prior to procedure initiation.

The patient was assessed for conscious sedation and found to be an adequate candidate. A dedicated nurse monitored heart rate, blood pressure, and oxygen saturation throughout the procedure. 

The right upper arm AV graft and overlying soft tissues were prepped and draped in sterile fashion. Ultrasonographic evaluation was carried out. Using local anesthetic and ultrasound guidance, the graft was punctured antegrade near the arterial anastomosis and an image transferred the PACS.  A 0.018″ wire was passed centrally and the needle exchanged for a 5 French transitional dilator. A minimal contrast injection was made to confirm location.

A 0.035” Glidewire was negotiated centrally and the dilator exchanged for a long 7 French sheath.   A repeat central venogram was performed from the sheath, confirming high-grade central venous stenosis at 2 sites.

Utilizing a Glidewire and 5 French catheter, the high-grade central lesion was traversed and the glide placed into the IVC. The glide was exchanged for an Amplatz wire.

An 8 mm x 4 cm Conquest balloon was advanced to the sites of central stenosis and inflated. The balloon was repositioned at the sites of 2 tandem venous anastomotic and venous outflow stenoses and again inflated. Contrast evaluation was performed.

Because of persistent collateral filling, the right central brachiocephalic venous and SVC stenoses were dilated to 12 mm. Again, there was persistent collateral filling. A 14 mm x 4 cm Atlas balloon was advanced to the site of stenoses and inflated.

Finally, the 2 tandem venous anastomotic and outflow stenoses were dilated with a 10 mm x 4 cm conquest balloon. The balloons were removed and contrast evaluation repeated.

The antegrade graftotomy was closed in purse-string fashion utilizing a “Woggle” device.

The procedure was well tolerated, and patient discharged in satisfactory condition.

Findings:

1. The     upper arm AV graft  patent.
2.   .

Impression: 

Successful percutaneous revision of a      upper arm AV graft.