Vascular help?!

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Can someone please help with this vascular surgery???


With the patient in the supine position and following
attainment of general endotracheal anesthesia, the left upper extremity was
prepped circumferentially with multiple layers of ChloraPrep and draped as
a sterile field. A transverse incision was made on the bicipital surface of
the distal left upper arm over the palpable brachial basilic AV fistula.
The AV graft was dissected free and encircled proximally and distally with
umbilical tapes which were converted to Rumel tourniquets. The patient was
heparinized with 3000 units of heparin and a transverse incision was made
in the AV graft which was completely thrombosed. A #4 Fogarty catheter was
passed proximally to the left subclavian vein under fluoroscopic control.
The balloon was inflated and the catheter was withdrawn. Under fluoroscopic
control, a large amount of thrombus was extracted. There appeared to be a
stenosis in the axillary vein at the level of the left shoulder joint
space. This was repeated until no further thrombus was extracted. The above-
mentioned angiogram was performed with the above findings.

A guidewire was then passed across the stenoses. The axillary vein stenoses
was initially dilated with an 8 mm Conquest balloon and following the
balloon dilatation a repeat angiogram showed persistent residual stenosis.
This was a 9 mm x 4 cm flared covered stent was placed across the stenosis
and deployed. A second straight covered stent was then placed to cover the
entire length of the stenosis. The stent was then formed with gentle
inflation of a 9 mm balloon. Post-stenting angiogram showed no residual
thrombosis.

Attention was then turned to the arterial and a Fogarty catheter was passed
distally in the AV graft from the graftotomy site. The balloon was
inflated, the catheter was withdrawn. A large amount of fresh thrombus with
a positive meniscus sign was extracted. Following this, there was brisk
arterial inflow. Again, a 6-French introducing sheath was introduced with
its tip directed inferiorly controlled with a Rumel tourniquet and a hand
injection technique was performed as mentioned above and the angiographic
findings of the brachial artery stenosis as mentioned above was identified.
A guidewire was passed across the stenosis and the stenosis was ballooned
with a 6 mm balloon. Post-balloon angioplasty completion angiogram showed
no residual of brachial artery stenosis. The balloon wire and introducing
sheath were removed. The graft was crossclamped distally. At this point,
the graftotomy was closed transversely with 2 running sutures of 6-0
Prolene, each being started laterally and medially in sewing to the middle
of the graftotomy. Prior to completion of closure, the back bleeding was
allowed to occur from the venous end and also from the arterial end. The
graft was recrossclamped. The graftotomy was secured. Both vascular clamps
were released. There was a palpable thrill in the AV graft in the mid upper
arm. The wound was irrigated with normal saline solution and closed in
layers with absorbable suture. The patient tolerated the procedure well and
was returned to the postanesthesia care unit with a palpable thrill over
the AV graft and an easily audible bruit.
 
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