PROCEDURE: RIGHT UPPER EXTREMITY FISTULOGRAM WITH ATTEMPTED REPAIR OF SUPERIOR VENA CAVA OCCLUSION

HISTORY: Chronic renal failure. Has a right upper extremity fistula. Recently, patient had dialysis showing high venous pressures. Fistulogram was ordered with intervention.

SERVICES PROVIDED:
1. Moderate sedation provided by the interventional radiology nurse and supervised by the radiologist using Fentanyl and Versed. Hemodynamic monitoring was performed during sedation.
2. Ultrasound guidance for right brachial artery access, permanent documentation of patency of right brachial artery was obtained.
3. Right brachial angiogram.
4. Right upper extremity fistulogram.
5. Central venogram and superior vena cavogram.
6. Ultrasound-guided puncture of right basilic vein with placement of a catheter in the right subclavian vein with subclavian venogram.
7. Ultrasound guidance for right common femoral puncture with superior vena cavogram. Placement of a catheter in the superior vena cava from a femoral approach.

CONSENT: The procedure, risks and benefits were explained to the patient. Informed consent was obtained. The right arm and right groin were prepped and draped in the usual manner. Moderate sedation was used for local anesthesia.

Using ultrasound guidance, right brachial artery was accessed without difficulty. Permanent documentation of patency and compressibility of the right brachial artery was obtained.

A 2.5-French catheter was introduced into the brachial artery. Right brachial angiogram and right upper extremity fistulogram was obtained.

A central superior vena cavogram was obtained as well.

FINDINGS: The fistula is patent. There is no evidence of stenosis at the arteriovenous anastomosis of the right forearm fistula. There is marked aneurysmal dilatation at the cephalic vein outflow.

Evaluation of the central veins revealed a short segment occlusion of the right brachiocephalic vein at the junction of superior vena cava. When patient was questioned, it appears that patient had previous PermCath insertions a long time ago prior to his fistula working which is 8 years ago. This is consistent with a chronic occlusion of the right brachiocephalic vein. There are chest wall collaterals.

At this point, using ultrasound guidance, the right basilic vein was accessed. A 5-French catheter was introduced into the subclavian vein. Attempted recanalization of the right brachiocephalic vein was unsuccessful due to the chronicity of the occlusion.

At this point, the right common femoral vein was accessed with ultrasound guidance. Permanent documentation of patency of the femoral vein was performed.


IMPRESSION
1. ANEURYSMAL DILATATION OF THE PROXIMAL FISTULA WITHOUT HIGH-GRADE STENOSIS AT THE ARTERIOVENOUS ANASTOMOSIS.

2. SHORT SEGMENT OCCLUSION OF THE RIGHT BRACHIOCEPHALIC VEIN.

3. ATTEMPTED RECANALIZATION THROUGH SHORT SEGMENT CEPHALIC VEIN WAS UNSUCCESSFUL FROM AN ARM AND FEMORAL APPROACH DUE TO THE CHRONICITY OF THE OCCLUSION FOR MORE THAN 6 YEARS.