DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Thrombosed right brachial-median antecubital loop forearm graft.
POSTOPERATIVE DIAGNOSIS: Thrombosed right brachial-median antecubital loop forearm graft due to severe intimal hyperplasia at the venous anastomosis and venous outflow obstruction.
OPERATION PERFORMED: Thrombectomy of right brachial-median antecubital AV graft.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old man who underwent a right brachial artery to median antecubital AV graft. The graft functioned for several months; however, the patient had experienced several episodes of thrombosis requiring thrombolysis and angioplasty of the venous outflow. A surgery is indicated to attempt to preserve the access site. We discussed the risks and benefits of surgery with the patient. He understood and gave consent to proceed.
DESCRIPTION OF OPERATION: The patient was brought to the operating room. The procedure was done with light sedation and local anesthesia. The right upper extremity was prepped and draped in the usual sterile manner. Lidocaine 1% was used for local anesthesia.
A transverse incision was made 1 cm distal to the antecubital crease, and the dissection was carried down through the previous incision through the venous limb and the arterial limb of the AV graft. The graft was well incorporated. There was no evidence of infection. The graft was dissected free of surrounding tissues. The venous end was dissected, freed down to the venous anastomosis. The arterial line was dissected, freed down to approximately 0.5 cm from the arterial anastomosis.
A longitudinal opening was made over the venous end of the AV graft. There was fresh thrombus noted in the graft. This was removed with forceps. There was intimal hyperplasia within the venous anastomosis. This was also removed with forceps. The only patent outflow was via the cephalic vein.
We were able to pass a #3 thrombectomy graft up the cephalic vein up to the level of the arm. We passed this several times and retrieved a small amount of clot and were able to achieve some venous backbleeding. Nonetheless, the cephalic vein appeared to be sclerotic with multiple stenoses that were not completely resolved with the thrombectomy. After several passes were performed, we felt that we could not do any more to improve the venous outflow.
We then made a transverse opening in the arterial limb of the graft. There was a fresh thrombus noted in the graft. We were able to remove the thrombus from the arterial anastomosis using a #3 thrombectomy catheter. We removed a small plug of thrombus and were able to restore excellent arterial inflow.
We then cleaned out the loop portion of the graft with multiple passes of a #4 thrombectomy catheter and an adherent clot removing catheter. This was then flushed with heparinized saline. The arterial anastomosis was also flushed with heparinized saline.
We then closed the transverse opening on the arterial limb and the longitudinal opening on the venous limb with running 7-0 Prolene suture. Prior to completing the anastomosis, flushing procedures were performed. There was excellent arterial inflow. The openings in the graft were then closed.
The patient had a palpable pulse in the graft. There was a faint thrill in the venous outflow. The patient had easily palpable right radial pulse. Based on the palpable pulse in the AV graft and a faint thrill in the venous outflow, we were concerned that the graft would most likely fail due to poor venous outflow.
We did not feel that at the present time more work should be done, and there is a fair chance that he would need access performed in another location.
Hemostasis was achieved. The wound was closed in layers. The patient tolerated the procedure well without complications.
