Any Suggestions?
SERVICES PROVIDED:
1. Diagnostic fistulogram.
2. Diagnostic angiogram. Left arm.
3. Angioplasty of the arteriovenous anastomosis.
4. Intravenous moderate sedation.
The procedure was explained in detail to the patient. Potential risks, benefits, and alternate therapies were discussed. All questions were answered and informed consent was obtained.
Patient's left arm fistulogram was examined with ultrasound. The left arm was sterilely scrubbed, prepped and draped in the standard fashion. IV moderate sedation was given throughout the procedure using IV Versed and fentanyl. The patient was monitored with automatic blood pressure cuff measurement, EKG, and pulse oximetry during the procedure. Medications were administered by an RN.
Patient's left arm was sterilely scrubbed, prepped and draped in the standard fashion. Local anesthetic was applied using 2% Xylocaine. Using ultrasound guidance and a micropuncture needle, access was gained into the cephalic vein distal to the arteriovenous anastomosis. The percutaneous access was dilated to accept a 3-French catheter. A diagnostic fistulogram was obtained including evaluation of the draining veins of the left arm and central venous structures. With extrinsic compression held, contrast was injected to opacify the feeding radial artery.
The patient's left upper arm was sterilely scrubbed, prepped and draped in the standard fashion. Local anesthetic was applied using 2% Xylocaine. Using ultrasound guidance and a micropuncture needle, access was gained into the distal brachial artery just above the elbow joint. The percutaneous access was dilated to accept a 3-French catheter. A diagnostic angiogram of the left forearm was then obtained identifying the tortuous radial artery and the patent superficial and deep palmar arches.
The 3-French catheter in the left cephalic vein was dilated to accept a 5-French introducer sheath. A 0.014 wire was then guided fluoroscopically across the arteriovenous anastomosis and into the radial artery of the forearm. The radial artery and anastomotic stenosis was then angioplastied using a 3-mm semi compliant balloon inflated to 3.28 mm in diameter. Postangioplasty fistulogram was then obtained.
The balloon and wire were then removed and hemostasis achieved at the cephalic vein as well as the distal brachial artery.
FINDINGS: Diagnostic fistulogram shows a cephalic vein to distal radial artery fistula of the left forearm with significant stenosis involving the cephalic vein at the arteriovenous anastomosis as well as a second stenosis of the radial artery just proximal to the arteriovenous anastomosis. The remainder of the cephalic vein is patent. There is tortuosity and kinking of the cephalic vein in the upper arm but adequate collateral flow across the antecubital vein to the basilic and brachial veins of the upper arm. The remainder of the cephalic, basilic, and brachial veins are patent. A left subclavicular transvenous pacer is identified. The left axillary, subclavian, and innominate veins are patent. A right IJ subcutaneously tunneled PermCath is also visualized. The superior vena cava is also patent.
Following angioplasty of the radial artery stenosis and arteriovenous anastomosis of stenosis with a 3.28-mm balloon, postangioplasty fistulogram shows marked improvement in flow across the fistula. Clinical examination of the forearm shows also marked improvement in pulsation within the cephalic vein.
IMPRESSION
1. SUCCESSFUL ANGIOPLASTY OF THE DISTAL RADIAL ARTERY STENOSIS AND ARTERIOVENOUS ANASTOMOTIC STENOSIS WITH A 3.28-MM SEMI COMPLIANT BALLOON RESULTING IN IMPROVEMENT IN ARTERIAL FLOW ACROSS THE UPPER LEFT FOREARM AV FISTULA.
2. IF CLINICAL SYMPTOMS PERSIST, THEN A REPEAT FISTULOGRAM CAN BE PERFORMED
SERVICES PROVIDED:
1. Diagnostic fistulogram.
2. Diagnostic angiogram. Left arm.
3. Angioplasty of the arteriovenous anastomosis.
4. Intravenous moderate sedation.
The procedure was explained in detail to the patient. Potential risks, benefits, and alternate therapies were discussed. All questions were answered and informed consent was obtained.
Patient's left arm fistulogram was examined with ultrasound. The left arm was sterilely scrubbed, prepped and draped in the standard fashion. IV moderate sedation was given throughout the procedure using IV Versed and fentanyl. The patient was monitored with automatic blood pressure cuff measurement, EKG, and pulse oximetry during the procedure. Medications were administered by an RN.
Patient's left arm was sterilely scrubbed, prepped and draped in the standard fashion. Local anesthetic was applied using 2% Xylocaine. Using ultrasound guidance and a micropuncture needle, access was gained into the cephalic vein distal to the arteriovenous anastomosis. The percutaneous access was dilated to accept a 3-French catheter. A diagnostic fistulogram was obtained including evaluation of the draining veins of the left arm and central venous structures. With extrinsic compression held, contrast was injected to opacify the feeding radial artery.
The patient's left upper arm was sterilely scrubbed, prepped and draped in the standard fashion. Local anesthetic was applied using 2% Xylocaine. Using ultrasound guidance and a micropuncture needle, access was gained into the distal brachial artery just above the elbow joint. The percutaneous access was dilated to accept a 3-French catheter. A diagnostic angiogram of the left forearm was then obtained identifying the tortuous radial artery and the patent superficial and deep palmar arches.
The 3-French catheter in the left cephalic vein was dilated to accept a 5-French introducer sheath. A 0.014 wire was then guided fluoroscopically across the arteriovenous anastomosis and into the radial artery of the forearm. The radial artery and anastomotic stenosis was then angioplastied using a 3-mm semi compliant balloon inflated to 3.28 mm in diameter. Postangioplasty fistulogram was then obtained.
The balloon and wire were then removed and hemostasis achieved at the cephalic vein as well as the distal brachial artery.
FINDINGS: Diagnostic fistulogram shows a cephalic vein to distal radial artery fistula of the left forearm with significant stenosis involving the cephalic vein at the arteriovenous anastomosis as well as a second stenosis of the radial artery just proximal to the arteriovenous anastomosis. The remainder of the cephalic vein is patent. There is tortuosity and kinking of the cephalic vein in the upper arm but adequate collateral flow across the antecubital vein to the basilic and brachial veins of the upper arm. The remainder of the cephalic, basilic, and brachial veins are patent. A left subclavicular transvenous pacer is identified. The left axillary, subclavian, and innominate veins are patent. A right IJ subcutaneously tunneled PermCath is also visualized. The superior vena cava is also patent.
Following angioplasty of the radial artery stenosis and arteriovenous anastomosis of stenosis with a 3.28-mm balloon, postangioplasty fistulogram shows marked improvement in flow across the fistula. Clinical examination of the forearm shows also marked improvement in pulsation within the cephalic vein.
IMPRESSION
1. SUCCESSFUL ANGIOPLASTY OF THE DISTAL RADIAL ARTERY STENOSIS AND ARTERIOVENOUS ANASTOMOTIC STENOSIS WITH A 3.28-MM SEMI COMPLIANT BALLOON RESULTING IN IMPROVEMENT IN ARTERIAL FLOW ACROSS THE UPPER LEFT FOREARM AV FISTULA.
2. IF CLINICAL SYMPTOMS PERSIST, THEN A REPEAT FISTULOGRAM CAN BE PERFORMED