HELP PLEASE... Excision puncture sites AVF

ksnively

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Hoping that someone could help me with this one.

Pre & Post Op Dx: Infected puncture sites, times two, left forearm arteriovenous dialysis fistula
Operations: 1. Excision of two puncture sites, left forearm arteriorvenous fistula
2. Left fistulograms

Clinical Indications: The patient has a functioning left Cimino arteriovenous fistula. He was admitted because of MRSA bacteremia. There were two puncture sites that he has used in a button hole technique. The patient's white blood cell count has persisted. his blood cultures recently have been negative.

(below is just the nitty gritty of the procedure)
Procedure: The incision in the left wrist over the radiocephalic anastomosis was reopened. Here the proximal portion of the cephalic vein was dissected and encircled with the vessel loop.

In the proximal thrid of the left forearm, the cephalic vein was exposed and controlled with the vessel loop. Having done so, I established procimal and distal control over the two puncture sites in the left forearm arteriovenous fistula.

With both of these areas occluded, the two puncture sites were excised with an elliptical incision down to and including the subcutaneous tissue and a portion oft he vein wall to where the puncture site was noted. There was no purulence noted.

The puncture sites in the vein was closed with a figure-of eight sutures of #6-0 Prolene. The incisions were then closed using #4-0 Vicryl for the subcutaneous and subcuticular closures. I had to add #4-0 Prolene sutures to clsoe the incision in a continuous mattress suture fashion.

Before closing the radiocephalic anastomotic site, a #4 French sheath was inserted into the cephalic vein. Fistulograms were obtained. There was no stenotic area noted along the course of the cephalic vein, the draining basilic and cephalic veins as well as the left axillary, subclavian and innominate veins.

The #4 French sheath was then removed over a figure-of-eight suture of #6-0 Prolene. Having been satisfied with hemostasis, the alst incision was closed using #4-0 Vicryl for subcutaneous and subcuticular closure reinforced with Steri-Strips. Sterile dressings were applied.

Thank you,
Kim
 
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