latonya78
Contributor
Procedure:
1. Left upper extremity AV dialysis graft declot
2. AV graft venous anastomosis angioplasty
3. Left upper extremity AV graft fistulogram
Indication: Clotted left upper extremity AV graft; ESRD
Anesthesia: General with ETT per anesthesiology.
Medications:
1% lidocaine local
4 mg TPA in 10 mL normal saline
Heparin 100 units/kg x1
Contrast: 50 mL Omnipaque 350
Fluoro time: 8.2 minutes.
Radiation exposure: 11.21 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.
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 6F 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 to 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. Then, the 6 mm x 4 cm conquest balloon was again
insufflated serially to macerate the thrombus. No wasting was seen at the
level of the venous anastomosis. The balloons were removed over wire. A
fistulogram 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. Completely thrombosed AV graft.
2. Widely patent is sonographically normal arterial anastomosis.
3. Moderate wasting of the 6 mm conquest balloon was seen at the
venous anastomosis, consistent with venous anastomotic stenosis.
4. Less than 10-20% residual stenosis observed at the venous
anastomosis following angioplasty. Because there was less than 30%
residual stenosis, the decision was made not stent the venous anastomosis.
CPT codes submitted are: Coded as: 35476, 76937, and 75978
1. Left upper extremity AV dialysis graft declot
2. AV graft venous anastomosis angioplasty
3. Left upper extremity AV graft fistulogram
Indication: Clotted left upper extremity AV graft; ESRD
Anesthesia: General with ETT per anesthesiology.
Medications:
1% lidocaine local
4 mg TPA in 10 mL normal saline
Heparin 100 units/kg x1
Contrast: 50 mL Omnipaque 350
Fluoro time: 8.2 minutes.
Radiation exposure: 11.21 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.
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 6F 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 to 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. Then, the 6 mm x 4 cm conquest balloon was again
insufflated serially to macerate the thrombus. No wasting was seen at the
level of the venous anastomosis. The balloons were removed over wire. A
fistulogram 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. Completely thrombosed AV graft.
2. Widely patent is sonographically normal arterial anastomosis.
3. Moderate wasting of the 6 mm conquest balloon was seen at the
venous anastomosis, consistent with venous anastomotic stenosis.
4. Less than 10-20% residual stenosis observed at the venous
anastomosis following angioplasty. Because there was less than 30%
residual stenosis, the decision was made not stent the venous anastomosis.
CPT codes submitted are: Coded as: 35476, 76937, and 75978