DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm.
1. Abdominal aortic aneurysm.
2. Bilateral iliac stenoses.
1. Endovascular abdominal aortic aneurysm repair.
2. Bilateral common iliac artery angioplasties.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIOLOGIST: Bradford Doe, MD
1. Primary device deployed via the left common femoral artery was a 23 mm x 12 mm x 16 cm Excluder bifurcated endoprosthesis.
2. Right contralateral limb was a 14 mm x 12 cm Excluder endoprosthesis.
3. After placement, high-grade bilateral common iliac artery stenoses remained. Angioplasty performed using 14 mm x 4 cm kissing balloons with 0% residual stenosis.
4. Completion angiogram revealed no evidence of endoleak with excellent proximal and distal seal.
DESCRIPTION OF OPERATION: The patient was brought to the interventional radiology suite. Support lines were placed. The patient had an arterial line, Foley catheter and intravenous lines placed preoperatively. He received 1 gram of Ancef. A spinal anesthetic was then secured. The patient was then placed in the supine position, and his abdomen and groins were prepped and sterilely draped. Dr. John Doe then performed bilateral common femoral artery cut-downs through oblique incisions down to the common femoral artery. The common femoral artery was isolated proximally and distally and encircled using vessel loops. Then, 5000 units of heparin was given intravenously. On the right, Dr. John Doe then cannulated the right common femoral artery and under fluoroscopic guidance advanced the wire into the suprarenal aorta. An 8 French sheath was then placed into the right groin.
On the left, Dr. Jane Doe then cannulated the left common femoral artery and advanced a wire into the suprarenal aorta. An 8 French sheath was placed into the left groin as well. The decision was made to deploy the right via the left femoral artery. Therefore, a pigtail catheter was placed over the wire into the left common femoral artery. The patient had a previous renal artery stent in the right renal artery and this was used as a marker. The patient had chronic renal insufficiency, and therefore, minimal contrast was used. Visipaque contrast was used during the procedure. An angiogram was performed which isolated the level of the renal arteries. Amplatz Super Stiff wires were then placed bilaterally. On the left, Dr. Jane Doe exchanged the sheath for an 18 French sheath. She advanced this up to the level of the renal arteries over the wire. The primary device, which was a 23 x 14 x 16 device, was chosen and it was advanced up to the level of the renal arteries. The sheath was withdrawn. Multiple angiograms were performed to reveal the appropriate position. Dr. Jane Doe then deployed the device. A 27 mm balloon was then placed into the proximal area and inflated gently to create a proximal seal.
Dr. John Doe then exchanged over an Amplatz wire for a 12 French sheath in the right groin. The sheath was pulled back into the sac and the contralateral limb was cannulated in a barber pole fashion. The catheter was advanced and dye was injected, as well as the balloon inflated to confirm that we were within the contralateral limb. An Amplatz Super Stiff device was then placed. The sheath was advanced up to the contralateral gate and measurements were performed. A 14 x 12 contralateral limb was chosen, and Dr. John Doe then passed this over the wire up to the appropriate position. The sheath was withdrawn and the device was deployed; 14 mm kissing balloons were then placed into the gate area and inflated to create a good seal. Angiogram revealed a high-grade stenosis in both the right and the left common iliac arteries that had been diagnosed preoperatively as well. The 14 mm balloons were then placed in a kissing fashion and inflated to perform angioplasty of the common iliac arteries. There was 0% residual stenosis.
The catheters were removed and a pigtail catheter was then reinserted above the renal arteries. A completion angiogram was performed, which revealed good flow through the graft. There was excellent position below the renal arteries and filling of the renal arteries. There were good proximal and distal seals without any evidence of endoleak. The small atretic left internal iliac artery did not have any flow, but this was of no clinical consequence.
At this point, the procedure was concluded. The wires and catheters were removed. The sheaths were removed from the groins and vascular clamps were placed on the femoral arteries. Dr. John Doe then repaired the arteriotomies using 5-0 Prolene suture. The clamps were released, restoring blood flow to the legs. There were excellent pulses after the procedure. Then, 50 mg of protamine was administered. Both femoral incisions were then closed in multiple layers using Vicryl suture. Sterile dressings were placed. The patient tolerated the procedure well and was transferred to the recovery room postoperatively.
DATE OF PROCEDURE: MM/DD/YYYY
1. Infected right internal jugular tunnel dialysis catheter.
2. Superior vena cava syndrome.
3. Failed multiple upper extremity dialysis access.
1. Removal of right internal jugular tunneled dialysis catheter.
2. Ultrasound evaluation of the left internal jugular vein.
3. Ultrasound-guided access of left internal jugular vein.
4. Nonselective catheterization of the atrium via left internal jugular vein approach.
5. Superior vena cava angioplasty with 6 x 4 and 8 x 4 Conquest balloon at 15 atmospheres for 1 minute.
6. Insertion of a 24 cm long temporary Schon XL tunneled catheter.
1. Superior venacavogram.
2. Postangioplasty superior vena cava angiogram.
3. Fluoroscopic guidance insertion of a temporary dialysis catheter.
SURGEON: John Doe, MD
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old male who presented with end-stage renal disease and failed multiple dialysis access. The patient initially had a left forearm graft, which failed subsequently. Left brachial artery to brachial vein graft at the mid arm failed. The patient also had a right arm access and is currently been dialyzed via right internal jugular tunnel dialysis catheter. The patient has had multiple previous central line access catheters. Also had LifeSite catheters inserted in the past. The patient had an ultrasound of the upper extremities, which showed a patent left internal jugular vein. Recommendation was for removal of the right internal jugular tunneled catheter and placement of a temporary catheter via left internal jugular vein if possible. Risks and benefits of the procedure were explained to the patient, and the patient was agreeable to pursue surgery and gave informed consent.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. Sedation was given to the patient by the anesthesia team. The left neck was prepped and draped in the usual sterile fashion. The left internal jugular vein was visualized with an ultrasound. The left IJ was accessed percutaneously using Seldinger technique. We were not able to advance the wire beyond the brachiocephalic vein into the superior vena cava. For this reason, a 5 French Pinnacle sheath was introduced over the wire into the brachiocephalic vein. A Kumpe catheter was introduced into the brachiocephalic vein. An angled Glidewire was used and we were able to advance it successfully into the atrium.
At this stage, access was kept to the left side and attention was then directed to the right internal jugular vein. The right neck was prepped and draped in the usual sterile fashion. Lidocaine 1% was used to infiltrate the Dacron cuff up high. An incision was carried down through the skin and subcutaneous tissue. The fibrous sheath was isolated. A Kelly clamp was placed around it. The sheath was opened using electrocautery. The Dacron cuff was felt to be incorporated but it exhibited signs of infection. The Dacron cuff was excised and removed and was sent for cultures. The fibrous sheath was closed with Vicryl suture. The subcutaneous tissue was closed with Vicryl. The skin was closed with interrupted nylon. Dry dressing was applied to the right neck. The patient tolerated that part of the procedure well.
Gowns and gloves were changed and then attention was directed to the left side. We introduced a 24 cm long Schon dialysis catheter. The catheter went in easily into the brachiocephalic vein. The brachiocephalic vein at superior vena cava junction was very tight. We were not able to advance the catheter over a wire across that lesion. The wire was then pulled and an angiogram was obtained. The patient had critical stenosis of the superior vena cava. It was estimated to be around 98%. An angled Glidewire was then used to cross the superior vena cava successfully into the atrium. A 7 French long sheath was introduced via the left internal jugular vein to the brachiocephalic vein. Angiogram of that location was obtained.
The patient was found to have a thrombus in the superior vena cava. It was very small and was not interfering with the flow from the top. A sequential angioplasty of the superior vena cava, 6 x 4 and 8 x 4 Conquest balloon at 15 atmospheres for 1 minute was obtained. Restoration of flow through the superior vena cava was noticeable. At this stage, we did not place any stent. The 24 cm long AngioDynamics temporary Schon dialysis catheter was introduced over wire directly into the atrium. This was done under fluoroscopic guidance. Injection of the catheter placement was performed. The catheter was beyond the stenotic area. The arterial side hole was within the stenotic area. The catheter was secured in place with interrupted nylon. It was tested and it appeared that where it was positioned was the best area for the inflow for the arterial and venous flush flow. Dry dressing was applied to the neck. The patient tolerated the procedure well.
1. Ultrasound evaluation of left internal jugular vein. The left internal jugular vein appeared to be patent. It was compressible and free of thrombus.
2. Superior venacavogram. There was 98% stenosis of the superior vena cava noticed, which required angioplasty.
3. Postangioplasty superior vena cava angiogram. There was recannulization of the superior vena cava. Residual stenosis was estimated to be around 40%. We did not elect to place a stent at this stage because of the patient’s overall condition.
4. Fluoroscopic guidance and insertion of a temporary dialysis catheter. The final position of the catheter was assured by fluoroscopy. The catheter was secured in place successfully without any problem.
RECOMMENDATIONS: We are very concerned that the patient might have endocarditis despite the fact that transthoracic echocardiogram was normal. We have also recommended waiting until sepsis and clinical condition improves. The patient will need to have an angioplasty and stenting of the superior vena cava. A tunneled catheter will also be placed prior to discharge. The patient will ultimately need bilateral upper extremity venogram to assess for patency of any veins that can be used for an arm access.