DATE OF PROCEDURE: MM/DD/YYYY
Chronic renal failure.
Chronic renal failure.
Insertion of arteriovenous graft in the right upper arm.
ANESTHESIA: Local with IV sedation.
INDICATIONS FOR PROCEDURE: This (XX)-year-old lady has chronic renal failure and is currently dialyzed with left internal jugular dialysis catheter, which is not working very well. She has had failed grafts in the left arm and as a result of some of the procedures had suffered a mild steal syndrome to the left hand. However, she does not have diabetes, and because of the fact that her catheter is not working well, I believe that we need to go to new graft in her right arm. I would like them to be able to use this soon, as the catheter is not working well at all, and therefore, we will place a Vectra graft.
DESCRIPTION OF PROCEDURE: With the patient on the operating table in the supine position, the right arm was sterilely prepped with Betadine all the way to the axilla and chest wall and draped sterilely. Marcaine 0.5% was used for local anesthesia throughout. An oblique incision overlying the artery, just above the antecubital fossa, was then anesthetized. An incision was made and the incision was carried down through the subcutaneous tissue through the fascia, and the brachial artery was identified. It measured about 3 mm and was soft and pliable without any signs of atherosclerotic change. It was mobilized for a distance about 2 cm. The upper arm was approached for transverse incision in the upper arm near the axilla, and the axillary vein was dissected out. This was quite large, being about 1 cm or slightly more in diameter. A posterior branch was ligated and divided, thus mobilizing the vein entirely.
Next, a tunnel for the Vectra graft was determined against the tunneling device and marked on the skin and then this was anesthetized with local anesthetic. The tunneler was passed and then the graft was passed through the tunneler, being a 6 mm Vectra graft. The arterial anastomosis was performed first. The graft was laid across the artery, cut to the appropriate angle, and then an inside anastomosis was made after making an arteriotomy of about 6 cm in length. The anastomosis was with running 7-0 Gore-Tex suture. The graft was occluded at one end and the clamps on the artery were released and blood flowed easily into the graft without significant bleeding from suture line. The graft was back flushed with heparinized saline and clamped next to the anastomosis.
The venous end was then determined for length and angles for anastomosis to the axillary vein. This anastomosis was sewn, 6-0 Prolene suture. Vascular clamps were applied to the vein. A venotomy of approximately 1.5 cm in length was made and then the graft was cut in the oblique angle to correspond for this anastomosis. The anastomosis was performed with running 6-0 Prolene sutures. Upon release of the clamps and once it was finished, there was good flow through the system with essentially no bleeding. Good thrill was palpable.
Next, the area was irrigated, both the axillary and the antecubital incisions, to check for hemostasis. Everything looked fine. The wounds were then closed in layers with interrupted 3-0 Vicryl for subcutaneous and running 4-0 Vicryl subcuticular with Mastisol and Steri-Strips for skin. A sterile dressing, gauze, and Kerlix were applied. There was good thrill present in the graft, and just prior to closure, the radial pulse was palpated, both with the graft occluded and with it open, and there was not a significant change in the thrill with or without the graft occluded thus indicating less than clinically significant steal. Mastisol and Steri-Strips were applied to the skin. A sterile dressing, gauze, and Kerlix were applied and the patient was transferred to the recovery room in stable condition. The patient tolerated the procedure well.