Access for Dialysis: Surgical and Radiologic Procedures - part 9 potx

337 Appendix I: Fifty Case Reports—Work in Progress AI Fig. A.13.1. Fig. A.13.2. Fig. A.12.1. 338 Access for Dialysis: Surgical and Radiologic Procedures AI Case Scenario #14: Traumatic Amputation Comments In this case the impaired arm was used; this principle may not always apply. The author has less favorable experience using a paralyzed arm, i.e., after a stroke, be- cause of contraction, atrophy causing swelling after access placement (lack of muscle pump for edema prevention). Fig. A.13.3. Fig. A.14.1. 339 Appendix I: Fifty Case Reports—Work in Progress AI Case Scenario #15: Cephalic Vein Branching Young female with a right forearm cephalic vein (CV) with early branching, a fairly common anatomy (Fig. A.15.1). The more dorsal branch (DB) continues into the upper arm CV and volar branch will become the median antecubital vein that will lead into the basilic vein at the medial aspect of the distal upper arm. Unless one of these branches is clearly significantly larger the author does not ligate the smaller at this initial surgery. Later, the less developed branch may be ligated to increase flow and size of the best developed vein branch. Case Scenario #16: Clotted Primary AV Fistula with Stenosis Debilitated, diabetic 50 year old rural man with signs from multiple central vein dialysis catheter placements (Fig. A.16.1). Left subclavian (!!) vein catheter of 2 months is his only dialysis access, which currently is malfunctioning (blue port does not pull). There is a left wrist old radiocephalic fistula (not shown) clotted at the anastomosis, but vein is still open (Fig. A.16.2). Pre-Op Evaluation Duplex Doppler shows occluded L IJ, open R IJ, open L SCV with current catheter; (we did not perform venogram of central veins. In an access center this would be done at time of surgery or radiology intervention. The cephalic vein has a tight area at (CV) with diameter of 2mm. (Duplex Doppler examination with a tourniquet on upper arm) (Fig. A.16.2). Fig. A.15.1. 340 Access for Dialysis: Surgical and Radiologic Procedures AI Fig. A.16.1. Options 1. Place RIJ split ash catheter. Remove L SCV catheter. Place L forearm PTFE graft. 2. Place L forearm PTFE graft. Keep L SCV catheter for ~ 2 weeks until graft used. 3. Primary AVF R forearm. R IJ split ash. 4. Change L SCV catheter over guidewire. Solution 1. At surgery a L PTFE loop graft was placed to fairly large superficial antecu- bital veins (no images). 2. R IJ attempted catheter fails, guidewires stopped at or below clavicula; loca- tion supports total occlusion of SCV RIJ junction (and stenotic site from subclavian vein catheters). Procedure aborted. 3. Left SCV manipulated. Poor “pull” of venous line, injected without VES. Red, arterial port works nicely (20cc/2 sec). Sutures to skin removed. Outer cuff at exit site removed, this is an Opti Flow ® (Bard) catheter. Communi- cated to nephrologist and dialysis unit to try to get by with this catheter for 2 weeks, then use PTFE and remove catheter. Comments In this case the antecubital veins were chosen because of the mid forearm cepha- lic vein stenosis. The long term graft survival of these PTFE conversions to already dilated veins may be in the 90% range (Appendix V, Fig. 5A). The pre op “vein mapping” with duplex Doppler is critical in cases like this in order to choose the optimal anastomosis site. 341 Appendix I: Fifty Case Reports—Work in Progress AI Case Scenario #17: Upper Arm AVF with Central Stenosis The patient is 60 year old with a right upper arm brachio-cephalic fistula (arrow) (Fig. A.17.1). There is a slightly dilated vein with a strong, hard pulse suggesting a more central stenosis. There is a pulse (flow) going down the forearm cephalic vein (at X, Fig. A.17.1). Options 1. Interventional radiology for fistulagram and possible balloon angioplasty. 2. Create a new fistula L upper arm where there is a quite good cephalic vein palpable from the antecubital fossa to the shoulder (Fig. A.17.1). Solution Patient was referred for fistulagram, showing two outflow stenoses, one mid cepha- lic upper arm (arrow, Fig. A.17.2) and at the cephalic-subclavian level (arrows, Fig. A.17.3), both of which were subjected to balloon angioplasty (Figs. A.17.4, A.17.5). The effect of these radiologic are likely to be temporary. Fig. A.16.2. 342 Access for Dialysis: Surgical and Radiologic Procedures AI Fig. A.17.2. Fig. A.17.1. 343 Appendix I: Fifty Case Reports—Work in Progress AI Fig. A.17.3. Fig. A.17.4. Fig. A.17.5. 344 Access for Dialysis: Surgical and Radiologic Procedures AI Fig. A.18.1. Fig. A.18.2. Case Scenario #18: Intering PTFE Interposition Graft A long venous graft/outflow stenosis may be technically awkward to patch (Fig. A.18.1). This area had previously been subjected to patch PTFE angioplasty (arrow, Fig. A.18.1). Also, the patched area is often badly scarred, making the “diseased” segment even longer. The new Intering graft provides an excellent material for inter- position between old graft and a wide open vein across the antecubital fossa (Figs. A.18.3, A.18.4). Solution The Intering graft (W.L. Gore & Associates Inc, Medical Products, Flagstaff, AZ 86003. Ph: 800-437-8181. www.goremedical.com) is usable when the antecubital fossa 345 Appendix I: Fifty Case Reports—Work in Progress AI Fig. A.18.4. Fig. A.18.3. is to be crossed. Unlike other “ringed” grafts on the market, the enforcement rings in this graft consist of condensed PTFE. The grafts currently are available in various lengths with 5 or 10 cm ringed sections with normal (standard) stretch PTFE of 5-20 cm on each side. The section without blue marking line represents the ringed portion (Fig. A.18.2). The graft can be cut and sutured through the rings (Fig. A.18.3). Comments The author has used the Intering in 9 cases. One has thrombosed. At surgery the rings now appear as bright rings (Fig. A.18.4). 346 Access for Dialysis: Surgical and Radiologic Procedures AI Case Scenario #19: Outflow Stenosis Elderly lady with decreasing dialysis efficacy. The 3 cm long hard outflow steno- sis can be palpated (Fig. A.19.1), and seen on Duplex Doppler (between arrows). At surgery the stenosis is mainly in the median antecubital vein (MAV) leading up to the basilic vein (BV). The BV is in moderate spasm from surgery (Fig. A.19.2). Solution A 4 cm segment of the 6 mm Intering graft was placed across the antecubital fossa (Fig. A.19.3). Comments This patient also demonstrates a bad but common dialysis unit habit, i.e., repeat needle punctures at the same small area (arrows, Fig. A.19.4), often contributing to fibrosis, graft stenosis and pseudoaneurysm formation. Fig. A.19.2. Fig. A.19.1. [...]... controlled above and below the abscess (Fig A.25.2) (Median nerve (MN) and brachial veins (BV) also shown) The affected arterial defect was resected and the artery reanastomosed (similar to previous Case #24) (Gore Tex® suture, CV-6, TT -9 ) (Fig A.25.3) The entire PTFE graft was removed; the tract drained with 1/2” Penrose drains for 48 hours 356 Access for Dialysis: Surgical and Radiologic Procedures Comments... (Tisseel®, Baxter 1627 Lake Look Road LC-IV, Deerfield, IL 60015 Phone: 80 0-4 2 3-2 090 ; www.tissuesealing.com) was applied and a small suction drain placed for 48 hours There was no recurrence at 3 weeks postop (Fig A.27.2) At the time of this publication going to the printer (12 weeks post op) still no recurrence 360 Access for Dialysis: Surgical and Radiologic Procedures AI Fig A.27.1 Fig A.27.2 Case... encapsulated gelatinous material is found (Fig A.26.2), typical for seroma formation The capsule was completely excised Fig A.26.1 358 AI Access for Dialysis: Surgical and Radiologic Procedures (Fig A.26. 3-4 ) The graft arterial (A) and venous (V) limbs are exposed at the bottom of the cavity (Fig A.26.5) The cavity was drained with a small JP drain for 48 hours No recurrence of this seroma occurred at nine... most distal vein anastomosis site to facilitate future revision and extension up the vein Fig A.33.1 Fig A.33.2 AI 368 Access for Dialysis: Surgical and Radiologic Procedures Case Scenario #34: No Dialysis Access AI This 51 year old overweight woman has no current working access She has a large hemangiomic nevus, excluding the left arm for access (Fig A.34.1) At time of left IJ percutaneous catheter placement... ischemia The upper arm graft was temporarily banded (at B, Fig A.30.2) but used for dialysis another 3 Fig A.30.1 364 Access for Dialysis: Surgical and Radiologic Procedures AI Fig A.30.2 weeks until the forearm graft was ready Then the upper arm graft was ligated close to the arterial anastomosis (clipped with large hemoclip) at arrow (Fig A.30.1) No further hand ischemia occurred Case Scenario #31: Multiple... angioplasty is the proper procedure (Fig A.21. 2-3 ), rather than an interposition graft Comments Each case is different and must be judged on its own merit; factors involved include outflow vein anatomy, length of stenosed segment, previous patch angioplasty and surgeons’ technique Fig A.21.1 Fig A.21.2 AI 350 Access for Dialysis: Surgical and Radiologic Procedures AI Fig A.21.3 Case Scenario #22: Outflow... less mobile than in the medial aspect (Fig A.33. 1-2 ); this is most obvious in females and after significant weight loss Also, the lateral aspect is less painful for needle sticks Appendix I: Fifty Case Reports—Work in Progress 365 AI Fig A.31.1 Fig A.31.2 Fig A.31.3 366 AI Fig A.32.1 Fig A.32.2 Fig A.32.3 Access for Dialysis: Surgical and Radiologic Procedures Appendix I: Fifty Case Reports—Work in... patch was sewn onto the graft-vein after successful declotting Note the large outflow veins (arrows, Fig A.20.3) Comments In this case a patch was chosen to preserve the third (v communicates) outflow vein In other situations the Intering graft interposition may be suitable (see Cases 1 8-1 9) 348 AI Fig A.20.1 Fig A.20.2 Fig A.20.3 Access for Dialysis: Surgical and Radiologic Procedures Appendix I: Fifty... case), it is safer to return in a relatively infection-free area and reconstruct the artery with vein patch, resection or direct closure pending local anatomy (see Chapter 4, Fig 4.28) Appendix I: Fifty Case Reports—Work in Progress 353 AI Fig A.23.1 Fig A.23.2 Fig A.23.3 354 AI Fig A.24.1 Fig A.24.2 Access for Dialysis: Surgical and Radiologic Procedures Appendix I: Fifty Case Reports—Work in Progress... L/min Both RA and UA are open but narrowed and severely calcified Left sided finger pressures are about 70 mmHg Right hand finger pressures are about 190 mmHg Appendix I: Fifty Case Reports—Work in Progress 361 Options 1 Ligate the left arm fistula and place an IJ dual lumen, tunneled catheter as the only access 2 Band the fistula between the aneurysms Solution Patient scheduled for banding surgery; . be suitable (see Cases 1 8-1 9) . Fig. A. 19. 4. Fig. A. 19. 3. 348 Access for Dialysis: Surgical and Radiologic Procedures AI Fig. A.20.3. Fig. A.20.2. Fig. A.20.1. 3 49 Appendix I: Fifty Case. Tex ® suture, CV-6, TT -9 ) (Fig. A.25.3). The entire PTFE graft was removed; the tract drained with 1/2” Penrose drains for 48 hours. 356 Access for Dialysis: Surgical and Radiologic Procedures AI . A.15.1. 340 Access for Dialysis: Surgical and Radiologic Procedures AI Fig. A.16.1. Options 1. Place RIJ split ash catheter. Remove L SCV catheter. Place L forearm PTFE graft. 2. Place L forearm