claning
Networker
Help! I haven't done very many of these and am not feeling the confidence on this one. I came up with 36830, 36558, 36589, 36010/XS, 37248, 37249 x2, 36901, 77001/XS, 76937, 75825/XU. What do you think? Seems too much to me, but I think it's separate!
thank you! Carol
Procedure:
1. Left upper extremity fistula creation with 4/6mm PTFE graft
2. Catheter placement into SVC
3. SVC venogram
4. IVC venogram
5. Venoplasty of the left internal jugular vein
6. Venoplasty of the subclavian vein, left innominate vein, and SVC
7. Excision of previous graft
9. Central vein stent graft placement of the superior vena cava, left brachiocephalic vein and internal jugular vein (HeRO graft)
10. Left arm fistulogram & left arm angiogram
11. Ultrasound guided access of common femoral vein
12. Right femoral perm catheter placement
13. Removal of left chest wall perm catheter
Findings:
Patent Left AV Graft
Patent HeRO graft with adequate outflow
Patent brachial artery flow to the radial and ulnar vessels
Description of procedure: The patient was brought to the Operating room and positioned in the supine position on the fluoroscopic table. All bony prominence were padded appropriately. Left arm regional block was given. A time-out and the appropriate site was marked and confirmed. Left neck, left upper extremity, chest and right groin were then shaved, prepped and draped in the usual standard sterile fashion. Preoperative antibiotics were given.
We started with placement of a permanent dialysis catheter fisrt. The dialysis catheter was flushed with heparin to ensure function of each port. The skin and subcutaneous tissue of the upper thigh and groin were anesthetized with 1% lidocaine. Using ultrasound guidance micropuncture needle was then used to access the femoral vein and the wire placement under fluoroscopy was performed and images were recorded. The stiff wire was placed in the infrarenal IVC.
At this point landmarks were identified and a stab incision was made on the anterolateral aspect of the upper thigh. Using the catheter tunneler the permanent catheter was tunneled towards the puncture site. The track was dilated. Peal away sheath was placed over wire into the iliac vein under fluoroscopy. At this point wire and inner dilator of the peel away sheath were removed. The permanent catheter was placed through the peal away sheath successfully. A spot fluoro was performed and catheter position was satisfactory. Each port was aspirated to ensure adequate blood flow and then flushed with heparinized saline solution. Each port had heparin solution placed. The Catheter was secured using 3-0 nylon suture and a sterile dressings applied.
Our attention was then turned to the left upper extremity. A 5 cm skin incision was then performed over the medial aspect of the upper arm towards the axilla, more proximal from his previous brachioaxillary graft. The incision was then deepened down through the subcutaneous tissue and fat. The aponeurosis of the biceps muscle was then identified with sharp dissection and incised and the brachial artery was palpated and its location was determined. The soft tissues over the brachial artery were incised and the brachial artery was circumferentially dissected and encircled. Patient had a very large arm and the dissection was reluctant given the body habitus. In the mid aspect of the upper arm we made a counterincision to assist with tunneling of the new PTFE graft but also to excise portion of the previous AV graft in order to allow for adequate tunneling. Part of the graft was sent to microbiology for further evaluation.
A 3 cm incision was made in the deltopectoral groove and using the Scanlon tunneler we created a subcutaneous tunnel connecting the incision in the upper arm to the incision in the deltopectoral groove. The tunnel was created in the anterior aspect of the upper arm to facilitate puncture sites for dialysis cannulations. The patient was given 2000 units of heparin intravenously. Yasargil clips were then applied to the brachial artery and a 6 mm arteriotomy was performed on anterior wall of the brachial artery. The end of a 4/6 mm tapered PTFE graft was spatulated to match the size of the arteriotomy. An anastomosis was then performed between the end of the PTFE graft and the arteriotomy using a 6-0 Prolene running suture. Forward and backbleeding from the brachial artery was performed. The anastomosis was then irrigated with heparinized saline Lucian. Sutures were tied and the anastomosis was checked for hemostasis, which was adequate. Flow was allowed to resume through the brachial artery. The PTFE graft was then introduced in the tunnel distended, avoiding any kinks or twists. Graft was then clamped near the anastomosis and irrigated with heparinized saline until clear fluid was seen irrigating out of the graft.
Attention was then directed towards the left internal jugular vein. A 1.5 cm incision was made at the previous left neck puncture site where the tunneled catheter inserts into the jugular vein. The catheter was then dissected free. Using a 035 wire we obtained access to the proximal superior vena cava by passing the wire through the venous port of the dialysis catheter. The neck region was reprepped to ensure adequate sterility. The catheter was then removed and exchanged with a guiding catheter that was placed into the SVC. A central venogram was then performed to evaluate patency of the central veins. Using our guiding catheter that was in the SVC, it enabled us to place a stiff wire in the distal aspect of the IVC in order to have adequate wire access control. We then performed a caval venogram to evaluate the patency of the IVC which was patent. Therefore, decision was made to intervene in order to have adequate pathway for the outflow component of the central stent graft (HeRO graft) to be placed comfortably. The patient required angioplasty of the internal jugular vein, subclavian vein, innominate vein and SVC in order to allow the stent graft to pass into the central venous system. The patient tolerated this aspect of the procedure well.
The left neck tract was dilated and a peel-away sheath was placed in the superior vena cava. Using the outflow HeRO stent graft component, we placed it in the IVC without difficulty. The stent graft was then flushed with heparinized saline solution. The connector component was then applied to the distal end of the stent graft and the PTFE graft and secured. Flow was allowed to be restored across the AVG and into the HeRO graft. We performed a left upper extremity fistulogram and adequate blood flow through the AV graft was identified and satisfactory. We further advanced our catheter into the brachial artery and a left upper extremity angiogram was performed that identified patent brachial artery and ulnar and radial vessels. The connector component was then secured to the surrounding subcutaneous tissue 3-0 vicryl suture.
All incisions were added with antibiotic saline solution. Incisions were then closed using 3-0 Vicryl suture for the subcutaneous tissue in an interrupted fashion. Skin Staples were applied. All instruments, sponges, needles, and catheters were correct ×2. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.
Plan: We'll plan to use the groin perm cath in a.m. if patient tolerates a full cycle of hemodialysis can be discharged home. Will await clearance of HeRO graft when patient follows up as outpt
thank you! Carol
Procedure:
1. Left upper extremity fistula creation with 4/6mm PTFE graft
2. Catheter placement into SVC
3. SVC venogram
4. IVC venogram
5. Venoplasty of the left internal jugular vein
6. Venoplasty of the subclavian vein, left innominate vein, and SVC
7. Excision of previous graft
9. Central vein stent graft placement of the superior vena cava, left brachiocephalic vein and internal jugular vein (HeRO graft)
10. Left arm fistulogram & left arm angiogram
11. Ultrasound guided access of common femoral vein
12. Right femoral perm catheter placement
13. Removal of left chest wall perm catheter
Findings:
Patent Left AV Graft
Patent HeRO graft with adequate outflow
Patent brachial artery flow to the radial and ulnar vessels
Description of procedure: The patient was brought to the Operating room and positioned in the supine position on the fluoroscopic table. All bony prominence were padded appropriately. Left arm regional block was given. A time-out and the appropriate site was marked and confirmed. Left neck, left upper extremity, chest and right groin were then shaved, prepped and draped in the usual standard sterile fashion. Preoperative antibiotics were given.
We started with placement of a permanent dialysis catheter fisrt. The dialysis catheter was flushed with heparin to ensure function of each port. The skin and subcutaneous tissue of the upper thigh and groin were anesthetized with 1% lidocaine. Using ultrasound guidance micropuncture needle was then used to access the femoral vein and the wire placement under fluoroscopy was performed and images were recorded. The stiff wire was placed in the infrarenal IVC.
At this point landmarks were identified and a stab incision was made on the anterolateral aspect of the upper thigh. Using the catheter tunneler the permanent catheter was tunneled towards the puncture site. The track was dilated. Peal away sheath was placed over wire into the iliac vein under fluoroscopy. At this point wire and inner dilator of the peel away sheath were removed. The permanent catheter was placed through the peal away sheath successfully. A spot fluoro was performed and catheter position was satisfactory. Each port was aspirated to ensure adequate blood flow and then flushed with heparinized saline solution. Each port had heparin solution placed. The Catheter was secured using 3-0 nylon suture and a sterile dressings applied.
Our attention was then turned to the left upper extremity. A 5 cm skin incision was then performed over the medial aspect of the upper arm towards the axilla, more proximal from his previous brachioaxillary graft. The incision was then deepened down through the subcutaneous tissue and fat. The aponeurosis of the biceps muscle was then identified with sharp dissection and incised and the brachial artery was palpated and its location was determined. The soft tissues over the brachial artery were incised and the brachial artery was circumferentially dissected and encircled. Patient had a very large arm and the dissection was reluctant given the body habitus. In the mid aspect of the upper arm we made a counterincision to assist with tunneling of the new PTFE graft but also to excise portion of the previous AV graft in order to allow for adequate tunneling. Part of the graft was sent to microbiology for further evaluation.
A 3 cm incision was made in the deltopectoral groove and using the Scanlon tunneler we created a subcutaneous tunnel connecting the incision in the upper arm to the incision in the deltopectoral groove. The tunnel was created in the anterior aspect of the upper arm to facilitate puncture sites for dialysis cannulations. The patient was given 2000 units of heparin intravenously. Yasargil clips were then applied to the brachial artery and a 6 mm arteriotomy was performed on anterior wall of the brachial artery. The end of a 4/6 mm tapered PTFE graft was spatulated to match the size of the arteriotomy. An anastomosis was then performed between the end of the PTFE graft and the arteriotomy using a 6-0 Prolene running suture. Forward and backbleeding from the brachial artery was performed. The anastomosis was then irrigated with heparinized saline Lucian. Sutures were tied and the anastomosis was checked for hemostasis, which was adequate. Flow was allowed to resume through the brachial artery. The PTFE graft was then introduced in the tunnel distended, avoiding any kinks or twists. Graft was then clamped near the anastomosis and irrigated with heparinized saline until clear fluid was seen irrigating out of the graft.
Attention was then directed towards the left internal jugular vein. A 1.5 cm incision was made at the previous left neck puncture site where the tunneled catheter inserts into the jugular vein. The catheter was then dissected free. Using a 035 wire we obtained access to the proximal superior vena cava by passing the wire through the venous port of the dialysis catheter. The neck region was reprepped to ensure adequate sterility. The catheter was then removed and exchanged with a guiding catheter that was placed into the SVC. A central venogram was then performed to evaluate patency of the central veins. Using our guiding catheter that was in the SVC, it enabled us to place a stiff wire in the distal aspect of the IVC in order to have adequate wire access control. We then performed a caval venogram to evaluate the patency of the IVC which was patent. Therefore, decision was made to intervene in order to have adequate pathway for the outflow component of the central stent graft (HeRO graft) to be placed comfortably. The patient required angioplasty of the internal jugular vein, subclavian vein, innominate vein and SVC in order to allow the stent graft to pass into the central venous system. The patient tolerated this aspect of the procedure well.
The left neck tract was dilated and a peel-away sheath was placed in the superior vena cava. Using the outflow HeRO stent graft component, we placed it in the IVC without difficulty. The stent graft was then flushed with heparinized saline solution. The connector component was then applied to the distal end of the stent graft and the PTFE graft and secured. Flow was allowed to be restored across the AVG and into the HeRO graft. We performed a left upper extremity fistulogram and adequate blood flow through the AV graft was identified and satisfactory. We further advanced our catheter into the brachial artery and a left upper extremity angiogram was performed that identified patent brachial artery and ulnar and radial vessels. The connector component was then secured to the surrounding subcutaneous tissue 3-0 vicryl suture.
All incisions were added with antibiotic saline solution. Incisions were then closed using 3-0 Vicryl suture for the subcutaneous tissue in an interrupted fashion. Skin Staples were applied. All instruments, sponges, needles, and catheters were correct ×2. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.
Plan: We'll plan to use the groin perm cath in a.m. if patient tolerates a full cycle of hemodialysis can be discharged home. Will await clearance of HeRO graft when patient follows up as outpt