36906, 36907, & 36908

nlbarnes

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PROCEDURES:
1. Ultrasound-guided percutaneous access of right upper extremity AV
graft.
2. Percutaneous mechanical thrombectomy of right upper extremity AV
graft with an AngioJet device and total of 4 mg of tPA.
3. Percutaneous transluminal angioplasty of right brachial artery
with a 5 mm x 60 mm angioplasty balloon.
4. Percutaneous transluminal angioplasty of right AV graft with an 8
mm x 60 mm angioplasty balloon.
5. Percutaneous transluminal angioplasty and stenting of right
axillary vein with a 9 mm x 60 mm self-expanding stent
post dilated with an 8 mm x 60 mm angioplasty balloon.
6. Percutaneous transluminal angioplasty of right subclavian vein
with a 10 mm x 40 mm angioplasty balloon.
7. Completion angiography.
8. Supervision and interpretation of the above.


DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine on the
operating table, had sedation induced with no complications. The
patient had right upper extremity prepped and draped in sterile
fashion. After local anesthetic infiltration, ultrasound was used to
percutaneously access to the right upper extremity AV graft in its
distal location, after which a guidewire and sheath were directed
toward the central venous circulation. A short 6-French sheath was
placed at this site. Ultrasound was then used to obtain a second
access in the proximal portion of the AV graft directed distally
toward the arterial anastomosis, after which a guidewire and sheath
were placed in the graft without difficulty. A second short 6-French
sheath was placed at this site. A stiff angled Glidewire was then
used to traverse the venous anastomosis with the wire passing into the
central venous circulation. The second stiff angled Glidewire was
then directed toward the arterial anastomosis and used to traverse it
with the wire into the central arterial circulation. At this time,
the patient was systemically heparinized with a total 5000 units of
intravenous heparin. The AngioJet device was then used to perform
percutaneous mechanical thrombectomy of the right upper extremity AV
graft. By power pulsing and total of 4 mg of tPA throughout the
thrombosed graft itself, after which a total of 150 mL of thrombectomy
was performed. After this was completed, flow was resumed in the
graft and initial fistulogram revealed significant greater than 90%
stenosis of the proximal venous anastomosis. At this time, a distal
angiogram was also performed which revealed significant stenosis at
the arterial anastomosis with some residual thrombus. Therefore, the
arterial anastomosis was treated with a 5 mm x 60 mm balloon followed
by treating a stenosis in the mid graft with an 8 mm x 60 mm balloon,
after which the venous anastomosis into the axillary vein was
angioplastied with a 7 mm x 60 mm balloon. At this time, there was
seen to be significant residual stenosis at the venous anastomosis
despite angioplasty; therefore, a 9 mm x 60 mm self-expanding stent
was deployed across the venous anastomosis into the axillary vein,
after which an 8 mm x 60 mm balloon was used to post-dilate this with
good angiographic result. A fistulogram was then performed which
revealed good patency of the graft itself. However, an area of
stenosis at the right subclavian vein. A 10 mm x 40 mm angioplasty
balloon was then used to angioplasty this with good angiographic 606423744
 
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