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Reason for Study: ULNAR STENOSIS
Reason For Visit: ANGIOGRAM L ARM 440.22/ SPECIAL PROCEDURES
30-year-old female with end-stage renal disease on hemodialysis. The
patient has a left arm AV graft and now has ischemic left fingers.
Medications:
1. Dilaudid 1.0 mg IV.
2. Phenergan 12.5 mg IV.
3. Isovue-250 150 mL.
Procedure Note: Using sterile technique and 1% lidocaine for local
anesthesia, a right common femoral arterial puncture was performed
and a 5 French vascular sheath was placed. A 5 French Weinberg
catheter was advanced up the aorta and was positioned with the
catheter tip in the ascending aorta. Contrast injections were made
and digital subtraction images of the upper chest and neck were
obtained. Selective catheterization of the left subclavian artery was
performed. Contrast injections were made and digital subtraction
images of the left upper extremity were obtained. The catheter was
further advanced into the left brachial artery where contrast
injections were made and digital subtraction images of the left upper
extremity were obtained with and without compression of the left arm
AV graft. The catheter and sheath were removed and hemostasis was
obtained with a Syvek patch. The patient tolerated the procedure well
without complications.
Findings:
Arch Aortogram: The aortic arch is patent and smooth. The proximal
brachiocephalic arteries are patent without evidence of stenosis. The
vertebral arteries are patent, bilaterally, with the right vertebral
artery being dominant. The distal subclavian arteries are patent and
smooth.
Left Upper Extremity Arteriogram: The left subclavian and axillary
arteries are patent and smooth. An arterial-venous graft is present
with the anastomosis from the brachial artery near the axilla. There
is a moderate to severe stenosis of the proximal AV graft likely
corresponding to the site of surgical banding of the graft.
Otherwise, the graft is widely patent. There is a moderate to severe
stenosis at the venous anastomosis of the graft, as well. There is a
slight decrease in the caliber of the brachial artery after the
anastomosis, but it is widely patent. The left ulnar artery is
diffusely very small in caliber and peters out at the level of the
wrist. Temporary occlusion of the AV graft did not have a significant
effect on the caliber of the ulnar artery. A small collateral is
present which extends from the ulnar artery into the wrist. The
intraosseous artery is patent. The left radial artery is patent and
fairly large in caliber. However, the deep palmar arch and the
superficial palmar arch are both incomplete. Digital arteries are
seen extending to the thumb, index finger, middle finger and ring
finger but no digital arteries could be demonstrated perfusing the
ring finger.
Impressions:
1. The left ulnar artery is diffusely small in caliber and peters out
at the wrist. A small collateral from the ulnar artery is present
which extends into the wrist.
2. Patent left radial artery. However, the deep palmar arch and
superficial palmar arch are both incomplete. We could not demonstrate
perfusion to the little finger.
3. Patent left arm AV graft. The graft has been surgically banded
with a resultant stenosis near the arterial anastomosis. There is
also a significant stenosis at the venous anastomosis of the graft.
Reason For Visit: ANGIOGRAM L ARM 440.22/ SPECIAL PROCEDURES
30-year-old female with end-stage renal disease on hemodialysis. The
patient has a left arm AV graft and now has ischemic left fingers.
Medications:
1. Dilaudid 1.0 mg IV.
2. Phenergan 12.5 mg IV.
3. Isovue-250 150 mL.
Procedure Note: Using sterile technique and 1% lidocaine for local
anesthesia, a right common femoral arterial puncture was performed
and a 5 French vascular sheath was placed. A 5 French Weinberg
catheter was advanced up the aorta and was positioned with the
catheter tip in the ascending aorta. Contrast injections were made
and digital subtraction images of the upper chest and neck were
obtained. Selective catheterization of the left subclavian artery was
performed. Contrast injections were made and digital subtraction
images of the left upper extremity were obtained. The catheter was
further advanced into the left brachial artery where contrast
injections were made and digital subtraction images of the left upper
extremity were obtained with and without compression of the left arm
AV graft. The catheter and sheath were removed and hemostasis was
obtained with a Syvek patch. The patient tolerated the procedure well
without complications.
Findings:
Arch Aortogram: The aortic arch is patent and smooth. The proximal
brachiocephalic arteries are patent without evidence of stenosis. The
vertebral arteries are patent, bilaterally, with the right vertebral
artery being dominant. The distal subclavian arteries are patent and
smooth.
Left Upper Extremity Arteriogram: The left subclavian and axillary
arteries are patent and smooth. An arterial-venous graft is present
with the anastomosis from the brachial artery near the axilla. There
is a moderate to severe stenosis of the proximal AV graft likely
corresponding to the site of surgical banding of the graft.
Otherwise, the graft is widely patent. There is a moderate to severe
stenosis at the venous anastomosis of the graft, as well. There is a
slight decrease in the caliber of the brachial artery after the
anastomosis, but it is widely patent. The left ulnar artery is
diffusely very small in caliber and peters out at the level of the
wrist. Temporary occlusion of the AV graft did not have a significant
effect on the caliber of the ulnar artery. A small collateral is
present which extends from the ulnar artery into the wrist. The
intraosseous artery is patent. The left radial artery is patent and
fairly large in caliber. However, the deep palmar arch and the
superficial palmar arch are both incomplete. Digital arteries are
seen extending to the thumb, index finger, middle finger and ring
finger but no digital arteries could be demonstrated perfusing the
ring finger.
Impressions:
1. The left ulnar artery is diffusely small in caliber and peters out
at the wrist. A small collateral from the ulnar artery is present
which extends into the wrist.
2. Patent left radial artery. However, the deep palmar arch and
superficial palmar arch are both incomplete. We could not demonstrate
perfusion to the little finger.
3. Patent left arm AV graft. The graft has been surgically banded
with a resultant stenosis near the arterial anastomosis. There is
also a significant stenosis at the venous anastomosis of the graft.