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

Case Scenario #15: Cephalic Vein Branching Young female with a right forearm cephalic vein CV with early branching, afairly common anatomy Fig.. The more dorsal branch DB continues intot

Fig A.13.1.

Fig A.13.2.

Fig A.12.1.

Fig A.13.3.

Fig A.14.1.

Case Scenario #15: Cephalic Vein Branching

Young female with a right forearm cephalic vein (CV) with early branching, afairly common anatomy (Fig A.15.1) The more dorsal branch (DB) continues intothe upper arm CV and volar branch will become the median antecubital vein thatwill 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 increaseflow 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 veindialysis catheter placements (Fig A.16.1) Left subclavian (!!) vein catheter of 2months is his only dialysis access, which currently is malfunctioning (blue port doesnot pull) There is a left wrist old radiocephalic fistula (not shown) clotted at theanastomosis, 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 currentcatheter; (we did not perform venogram of central veins In an access center thiswould be done at time of surgery or radiology intervention The cephalic vein has atight area at (CV) with diameter of 2mm (Duplex Doppler examination with atourniquet on upper arm) (Fig A.16.2)

Fig A.15.1.

3 Primary AVF R forearm R IJ split ash.

4 Change L SCV catheter over guidewire

loca-3 Left SCV manipulated Poor “pull” of venous line, injected without VES.Red, arterial port works nicely (20cc/2 sec) Sutures to skin removed Outercuff 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 2weeks, then use PTFE and remove catheter

Comments

In this case the antecubital veins were chosen because of the mid forearm lic vein stenosis The long term graft survival of these PTFE conversions to alreadydilated veins may be in the 90% range (Appendix V, Fig 5A) The pre op “veinmapping” with duplex Doppler is critical in cases like this in order to choose theoptimal anastomosis site

1 Interventional radiology for fistulagram and possible balloon angioplasty

2 Create a new fistula L upper arm where there is a quite good cephalic veinpalpable from the antecubital fossa to the shoulder (Fig A.17.1)

Solution

Patient was referred for fistulagram, showing two outflow stenoses, one mid 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

cepha-Fig A.16.2.

Fig A.17.2.

Fig A.17.1.

Fig A.17.3.

Fig A.17.4.

Fig A.17.5.

The Interinggraft (W.L Gore & Associates Inc, Medical Products, Flagstaff, AZ

86003 Ph: 800-437-8181 www.goremedical.com) is usable when the antecubital fossa

The author has used the Intering in 9 cases One has thrombosed At surgery therings now appear as bright rings (Fig A.18.4)

Case Scenario #19: Outflow Stenosis

Elderly lady with decreasing dialysis efficacy The 3 cm long hard outflow sis can be palpated (Fig A.19.1), and seen on Duplex Doppler (between arrows) Atsurgery the stenosis is mainly in the median antecubital vein (MAV) leading up tothe basilic vein (BV) The BV is in moderate spasm from surgery (Fig A.19.2)

Fig A.19.2.

Fig A.19.1.

Case Scenario #20: PTFE Patch Angioplasty

Classic case with AV graft thrombosis preceded by increasing venous dialysismachine pressures last several months Preoperatively, two outflow veins can be feltpatent (i.e., median antecubital vein (MAV) and the branch leading to the upperarm cephalic vein (CV)) (Fig A.20.1) At surgery there is also a vena communicatesthat can be seen inside the opened graft (arrow, Fig A.20.2) An AccusealPTFEpatch was sewn onto the graft-vein after successful declotting Note the large out-flow veins (arrows, Fig A.20.3)

Comments

In this case a patch was chosen to preserve the third (v communicates) outflowvein In other situations the Interinggraft interposition may be suitable (see Cases18-19)

Fig A.19.4.

Fig A.19.3.

Fig A.20.3.

Fig A.20.2.

Fig A.20.1.

Thrombosed PTFE AV graft At surgery there are, in addition to a large bital vein, two additional outflow veins, one of which is the vena anastomotica (VA)(Fig A.21.1) and one vein going distally (V) (Fig A.21.1) Both of these veins wereeasily flushed with saline without resistance To preserve these venous outflows a patchangioplasty is the proper procedure (Fig A.21.2-3), rather than an interposition graft

antecu-Comments

Each case is different and must be judged on its own merit; factors involvedinclude outflow vein anatomy, length of stenosed segment, previous patch angioplastyand surgeons’ technique

Fig A.21.2.

Fig A.21.1.

Case Scenario #22: Outflow Vein Occlusion

Middle aged woman with lupus nephropathy The PTFE graft loop has beenanastomosed to the basilic vein (BV) mid-forearm (Fig A.22.1) There is an almostcomplete obstruction of the basilic vein proximally with large venous collateral plexusgoing into distal forearm and hand (Fig A.22.1), more dramatically visualized on afistulagram (Fig A.22.2) Duplex Doppler reveals no usable veins in the antecubitalfossa A sizable basilic vein is first reconstituted at mid upper arm at arrow (Fig A.22.3)

Solution

At surgery a PTFE Intering graft was placed across the antecubital fossa betweenthe old graft and upper arm basilic vein (BV) The basilic vein distally was ligatedrelieving pressure/pain symptoms The 5 cm Intering section (IR) was placed at theelbow joint level (Fig A.22.4), as indicated by the skin markings

Fig A.21.3.

Fig A.22.1.

Fig A.22.2.

Fig A.22.3.

Fig A.22.4.

Comments

This represents another use for the Intering graft when passing the elbow joint.The Intergraft is currently available as 5 or 10 cm segments with 20 and 5 cmstretch Gore Tex graft on either side respectively The ring segment can be cut andsutured if needed The rings consist of condensed PTFE (see Fig A.18.2-A.18.4)

Case Scenario #23: Exposed Sutures

This 17 year old girl comes with this clotted left forearm PTFE graft 4 weeksafter placement (Fig A.23.1) Antecubital fossa detailed in Fig A.23.2 Simple physi-cal exam shows an adequate cephalic vein right forearm At surgery a right IJ duallumen catheter and a right forearm primary AV fistula placed The AV fistula devel-oped nicely She had a living donor kidney transplant before the AV fistula was used.The IJ catheter was kept through post transplant day 5 for anti thymocyte globulininfusion The AV fistula is still in place, working

Comments

This case demonstrates a combination of poor judgment or lack thereof as well

as poor surgical technique on the surgeon’s part

Case Scenario #24: Cutaneous Fistula

Infected PTFE right upper arm graft was removed 6 weeks ago Patient presentswith a cutaneous fistula (CF) (Fig A.24.1) over the arterial anastomosis site where asmall remnant of the graft was oversewn At surgery the brachial artery (BA) wasexposed and controlled above and below the infected PTFE (Fig A.24.2) The in-fected piece of PTFE was excised from the artery (Fig A.24.3), leaving a defect inthe artery Direct closure would have severely stenosed the artery Therefore, theartery was divided at 45° angle; each end of the artery rotated 90° and reanastomosedwith 7-0 Prolene®, BV-1 needle (Fig A.24.4)

Comments

It is common practice (including the author’s) to leave a small remnant ~ 0.5-1.0

cm of the PTFE oversewn at the arterial anastomosis In the majority of cases thisarea heals with no further problems Should problems arise (as in this 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)

Fig A.23.3.

Fig A.23.1.

Fig A.23.2.

Fig A.24.2.

Fig A.24.1.

Fig A.24.4.

Fig A.24.3.

Case Scenario #25: Infected Pseudoaneurysm

Infected, pulsating pseudoaneurysm at brachial artery PTFE anastomosis abovethe antecubital fossa (Fig A.25.1) The graft runs lateral up on the upper arm withthe venous anastomosis to proximal basilic/brachial vein This problem needs to beaddressed urgently

Solution

At surgery, the brachial artery (BA) was controlled above and below the abscess(Fig A.25.2) (Median nerve (MN) and brachial veins (BV) also shown) The af-fected arterial defect was resected and the artery reanastomosed (similar to previousCase #24) (Gore Tex® suture, CV-6, TT-9) (Fig A.25.3) The entire PTFE graftwas removed; the tract drained with 1/2” Penrose drains for 48 hours

Fig A.25.3.

Case Scenario #26: AV Graft Anastomosis Seroma

Sixty year old female one year after PTFE placement with this expandingnontender, non -pulsating, bulging mass (Fig A.26.1) Arterial (pull) and venous(return) graft sides are marked At surgery, encapsulated gelatinous material is found(Fig A.26.2), typical for seroma formation The capsule was completely excised

Fig A.26.1.

Fig A.26.5.

Fig A.26.6.

Case Scenario #27: Seroma

This is a 72 year old male with another tense (Fig A.27.1) seroma that failedexcision and drainage (Fig A.27.1) He relapsed and another gelatinous mass wasremoved 3 weeks later; at this time the floor in the cavity including the PTFE graftwas extensively cleaned from all gelatinous material The human thrombin spray(Tisseel®, Baxter 1627 Lake Look Road LC-IV, Deerfield, IL 60015 Phone:800-423-2090; www.tissuesealing.com) was applied and a small suction drain placedfor 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

Case Scenario #28: Chronic Steal

This patient is a 63 year old with type II diabetes for 20 years and a left upperarm brachiocephalic fistula of 2.5 months (Fig A.28.1) (9/11/01) This fistula isworking nicely It has 2 aneurysms with a short segment of normal fistula vein inbetween (arrow) of about 3-4 cm He now comes with dry distal ulcerations on allbut digit V (Fig A.28.2) There is numbness but no pain Both hands are cold, more

so on the left There are early dry ulcers on digit III right side Duplex Dopplerestimated flow is 2.2 L/min Both RA and UA are open but narrowed and severelycalcified Left sided finger pressures are about 70 mmHg Right hand finger pres-sures are about 190 mmHg

Fig A.27.2.

Fig A.27.1.

Fig A.28.1.

Fig A.28.2.

Case Scenario #29: Shiny Pseudoaneurysm

This type of quite small, paper thin aneurysm will eventually develop necrosisand bleed (Fig A.29.1, A.29.2) Occasionally the skin is so thin that the turbulentblood (red cell) flow can be seen At surgery, proximal and distal control of the graftmust be obtained Alternatively, if there is only one or two small aneurysms a stitch

in the graft may suffice in a bloodless arm obtained with an upper arm tourniquet

Comments

Aneurysms come in all forms and shapes; do not operate just because there is ananeurysm, or because the referring doctor and the patient are concerned Surgery isindicated when infection is present, risk of rupture through shiny skin or under ascab Other indications include bothersome aneurysm because of size and location,and when associated with other complications such as stenosis

Fig A.29.1.

Fig A.28.3.

Case Scenario #30: Multiple Shiny Aneurysms

Patient with scleroderma Her upper arm entire PTFE graft is covered with small,paper-thin pseudoaneurysms (Fig A.30.1) Eventually, these are likely to necrose(and be inflamed) causing significant bleeding In some of these turbulent bloodflow can be seen with the bare eye After much discussion and workup (duplexDoppler, finger pressures) the patient had a forearm AV graft placed in the sameextremity (Fig A.30.1) She developed significant hand ischemia The upper armgraft was temporarily banded (at B, Fig A.30.2) but used for dialysis another 3

Fig A.30.1.

Fig A.29.2.

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) Nofurther hand ischemia occurred

Case Scenario #31: Multiple Pseudoaneurysms

In cases of multiple small (paper thin) aneurysms a longer (Fig A.31.1-2) ment of the graft with the skin may be excised Inside the graft large defects demon-strate the often extensive destruction of the graft (Fig A.31.3) with multiplecommunicating channels

seg-Case Scenario #32: Forearm PTFE

Pseudoaneurysms

Patient with an expanding (<4 weeks) dialysis needle induced pseudoaneurysm(Fig A.32.1) There is some pain but the protruding lump was bothersome andindicated its resection

At surgery the aneurysm was completely mobilized and the PTFE graft trolled on each side (Fig A.32.2) Before the second anastomosis the aneurysm andoutflow vein are flushed with heparinized (10u/ml) saline (Fig A.32.3)

con-Case Scenario #33: Upper Arm PTFE AV Graft

This case illustrates several aspects of upper arm access First, the major section

of the graft should be on the lateral or outermost aspect of the arm where the skin isfirmer and less mobile than in the medial aspect (Fig A.33.1-2); this is most obvi-ous in females and after significant weight loss Also, the lateral aspect is less painfulfor needle sticks

Fig A.31.3.

Fig A.31.1.

Fig A.31.2.

Fig A.32.1.

Fig A.32.2.

Fig A.32.3.

Second, the selection of anastomosis sites is greatly facilitated through tive Doppler “vein mapping”, where the surgeon is present to mark the exact site(arrow)

preopera-Third, select the most distal vein anastomosis site to facilitate future revision andextension up the vein

Fig A.33.1.

Fig A.33.2.

Case Scenario #34: No Dialysis Access

This 51 year old overweight woman has no current working access She has alarge hemangiomic nevus, excluding the left arm for access (Fig A.34.1) At time ofleft IJ percutaneous catheter placement 10 days ago patient became hoarse There is

a failed right forearm AV graft for 6 months She has had several right IJ catheters.Pre op duplex Doppler shows the cephalic vein patent along upper arm to the sub-clavian vein (visible in Fig A.34.2) Right IJ is occluded midneck but open at thecollar bone level

Fig A.34.1.

Fig A.34.2.

Solution

At surgery a PTFE AV graft was placed around the old graft right forearm (Fig.A.34.2) A low stick under direction with Site Rite using micropuncture techniquewas used to place a 28 cm right IJ split ash catheter The left percutaneous IJ catheterwas removed

Comments

Patient hoarseness resolved slowly within 7-10 days This is the only time theauthor has come across this complication Aberrant recurrent laryngeal nerve? He-matoma related to nevus? Or a “bad” stick?

Case Scenario #35: A Case of System Problems

Many case scenarios illustrate the importance of history taking, physical examand the use of duplex Doppler in coming to a workable solution During the examthe author uses a marking pen to outline old grafts, veins and arteries (Fig.A.35.1).This arm belongs to a slightly debilitated and obese 38 year old lady in whom Iplaced a primary AV fistula (AV) at the wrist 11 months ago The dialysis unit nursetold the patient that the fistula has not matured and that she needs a graft; thepatient, because of transportation problems, went to a closer local hospital and thesurgeon placed an AV loop graft (PTFE) that “never worked” in the patient’s ownwords There is a large palpable basilic vein (BV) and a large cephalic vein (CV) atthe antecubital fossa Duplex Doppler confirms these findings; in addition the di-ameter of the cephalic vein 3 cm from the anastomosis is 8 mm, with a flow rate ofabout 1200 cc/min Also, the cephalic vein divides beneath the clotted PTFE graftwith a large branch likely connecting to the BV at the antecubital fossa

Fig A.35.1.