TWilliam2019
Guru
Procedure Details:
After consent was obtained the patient was taken to the operative suite and laid in the supine position. The patient was placed under monitored anesthesia care and bilateral groins were prepped and draped in the usual sterile fashion. A proper timeout was performed and agreed upon by all parties present. Ultrasound was used to gain access to the left common femoral artery.
Ultrasonographic findings: The left common femoral artery is patent without significant atherosclerotic disease. Ultrasound guidance demonstrate successful cannulation of the common femoral artery and intraluminal needle placement. Ultrasound was used to evaluate potential access sites for patency. The target vessel was then accessed under real-time ultrasound guidance verifying intravascular needle entry. Images are not stored in the chart due to equipment capabilities. Systemic heparin was given and allowed to circulate.
A wire was passed into the external iliac artery and a 5 French sheath was placed and flushed with heparinized saline. Universal flush catheter was guided over 0.035 wire into the abdominal aorta and an abdominal aortogram was performed.
AORTOGRAM FINDINGS:
The abdominal aorta is patent. The celiac and superior mesenteric arteries fill with contrast. The right renal artery is patent. The left renal artery is patent. The right common iliac artery is patent. The right external iliac artery is patent. The left common iliac artery is patent. The left external iliac artery is patent. The right internal iliac artery is patent. The left internal iliac artery is patent.
To improve imaging, the catheter was moved to the level of the aortic bifurcation and arteriogram performed. The right common femoral artery and profunda femoral artery is patent. The proximal right superficial femoral artery is patent. The right femoral vein and profunda femoral vein almost immediately fill with contrast and fill the iliac veins and IVC which appear patent, but indicating arteriovenous fistula. The location is not clear at this point. The left common femoral artery and profunda femoral artery is patent. The left proximal superficial femoral artery is patent.
The universal flush catheter was guided over the aortic bifurcation into the right common femoral artery and a right lower extremity arteriogram was performed.
RIGHT LOWER EXTREMITY ARTERIOGRAM FINDINGS:
The common femoral artery is patent.
The profunda femoral artery is patent.
The superficial femoral artery is patent.
The right SFA was selected out with the wire and the catheter advanced and lower extremity arteriogram performed.
The popliteal artery is patent.
The anterior tibial artery is patent.
The tibioperoneal trunk is patent.
The posterior tibial artery is patent.
The peroneal artery is patent.
The sheath was exchanged for a 6 French by 10 cm sheath which was used to dilate the tract and then upsized to a 8 French by 45 cm sheath and flushed with heparinized saline. Repeat arteriogram performed of the right femoral arteries through the sheath and again the AV fistula is almost immediately seen in location not distinct. Multiple views of the right femoral vessels were performed. The right profundofemoral artery was selected out with a Glidewire and angled catheter advanced into the profundofemoral artery and selective arteriogram performed. The profunda femoral artery appeared patent without evidence of AV fistula. The catheter was then pulled back into the common femoral artery and the right superficial femoral artery was selected out with a Glidewire and catheter advanced and again arteriogram performed in the femoral veins filled up with contrast indicating AV fistula but unclear if this was due to reflux into the common femoral artery or if it was in the SFA. I then used a 7 mm x 20 mm balloon to isolate the proximal superficial femoral artery and repeated the arteriogram in which the AV fistula was still seen but the balloon size was undersized. The balloon was then upsized to an 8 mm x 20 mm balloon and balloon insufflation was performed in the proximal superficial femoral artery just distal to the profunda bifurcation and arteriogram performed through the balloon and AV fistula still apparent. This indicated superficial femoral artery to femoral vein AV fistula location. I then advanced the 8 mm x 20 mm balloon a couple centimeters distal from the SFA origin repeat arteriogram showed patent right SFA artery with exclusion of the AV fistula identifying its exact location. This was marked out on the screen. I then used the intravascular ultrasound to image the right common femoral artery and superficial femoral artery and measurements taken. A 9 mm x 29 mm VBX balloon mounted stent was chosen and guided into the right superficial femoral artery at the location of the AV fistula and balloon insufflation performed to nominal atmospheres deploying the stent across the AV fistula successfully. Repeat arteriogram shows successful exclusion of the AV fistula with patency of the right common femoral artery profundofemoral artery and SFA. There was contrast flowing into the venous system at this point. The sheath was pulled back into the proximal right external iliac artery and again a repeat arteriogram showed no evidence of residual AV fistula. Satisfied with the result the sheath was removed and the access site was closed with a Pro-glide. Hemostasis was achieved. Patient tolerated the procedure well. Patient has triphasic dopplerable signals following the procedure.
After consent was obtained the patient was taken to the operative suite and laid in the supine position. The patient was placed under monitored anesthesia care and bilateral groins were prepped and draped in the usual sterile fashion. A proper timeout was performed and agreed upon by all parties present. Ultrasound was used to gain access to the left common femoral artery.
Ultrasonographic findings: The left common femoral artery is patent without significant atherosclerotic disease. Ultrasound guidance demonstrate successful cannulation of the common femoral artery and intraluminal needle placement. Ultrasound was used to evaluate potential access sites for patency. The target vessel was then accessed under real-time ultrasound guidance verifying intravascular needle entry. Images are not stored in the chart due to equipment capabilities. Systemic heparin was given and allowed to circulate.
A wire was passed into the external iliac artery and a 5 French sheath was placed and flushed with heparinized saline. Universal flush catheter was guided over 0.035 wire into the abdominal aorta and an abdominal aortogram was performed.
AORTOGRAM FINDINGS:
The abdominal aorta is patent. The celiac and superior mesenteric arteries fill with contrast. The right renal artery is patent. The left renal artery is patent. The right common iliac artery is patent. The right external iliac artery is patent. The left common iliac artery is patent. The left external iliac artery is patent. The right internal iliac artery is patent. The left internal iliac artery is patent.
To improve imaging, the catheter was moved to the level of the aortic bifurcation and arteriogram performed. The right common femoral artery and profunda femoral artery is patent. The proximal right superficial femoral artery is patent. The right femoral vein and profunda femoral vein almost immediately fill with contrast and fill the iliac veins and IVC which appear patent, but indicating arteriovenous fistula. The location is not clear at this point. The left common femoral artery and profunda femoral artery is patent. The left proximal superficial femoral artery is patent.
The universal flush catheter was guided over the aortic bifurcation into the right common femoral artery and a right lower extremity arteriogram was performed.
RIGHT LOWER EXTREMITY ARTERIOGRAM FINDINGS:
The common femoral artery is patent.
The profunda femoral artery is patent.
The superficial femoral artery is patent.
The right SFA was selected out with the wire and the catheter advanced and lower extremity arteriogram performed.
The popliteal artery is patent.
The anterior tibial artery is patent.
The tibioperoneal trunk is patent.
The posterior tibial artery is patent.
The peroneal artery is patent.
The sheath was exchanged for a 6 French by 10 cm sheath which was used to dilate the tract and then upsized to a 8 French by 45 cm sheath and flushed with heparinized saline. Repeat arteriogram performed of the right femoral arteries through the sheath and again the AV fistula is almost immediately seen in location not distinct. Multiple views of the right femoral vessels were performed. The right profundofemoral artery was selected out with a Glidewire and angled catheter advanced into the profundofemoral artery and selective arteriogram performed. The profunda femoral artery appeared patent without evidence of AV fistula. The catheter was then pulled back into the common femoral artery and the right superficial femoral artery was selected out with a Glidewire and catheter advanced and again arteriogram performed in the femoral veins filled up with contrast indicating AV fistula but unclear if this was due to reflux into the common femoral artery or if it was in the SFA. I then used a 7 mm x 20 mm balloon to isolate the proximal superficial femoral artery and repeated the arteriogram in which the AV fistula was still seen but the balloon size was undersized. The balloon was then upsized to an 8 mm x 20 mm balloon and balloon insufflation was performed in the proximal superficial femoral artery just distal to the profunda bifurcation and arteriogram performed through the balloon and AV fistula still apparent. This indicated superficial femoral artery to femoral vein AV fistula location. I then advanced the 8 mm x 20 mm balloon a couple centimeters distal from the SFA origin repeat arteriogram showed patent right SFA artery with exclusion of the AV fistula identifying its exact location. This was marked out on the screen. I then used the intravascular ultrasound to image the right common femoral artery and superficial femoral artery and measurements taken. A 9 mm x 29 mm VBX balloon mounted stent was chosen and guided into the right superficial femoral artery at the location of the AV fistula and balloon insufflation performed to nominal atmospheres deploying the stent across the AV fistula successfully. Repeat arteriogram shows successful exclusion of the AV fistula with patency of the right common femoral artery profundofemoral artery and SFA. There was contrast flowing into the venous system at this point. The sheath was pulled back into the proximal right external iliac artery and again a repeat arteriogram showed no evidence of residual AV fistula. Satisfied with the result the sheath was removed and the access site was closed with a Pro-glide. Hemostasis was achieved. Patient tolerated the procedure well. Patient has triphasic dopplerable signals following the procedure.