DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: End-stage renal disease.
POSTOPERATIVE DIAGNOSIS: End-stage renal disease.
1. Attempt at right internal jugular vein aspiration.
2. Left internal jugular venogram.
3. Placement of left internal jugular hemodialysis catheter under fluoroscopic guidance.
SURGEON: John Doe, MD
ANESTHESIA: Local MAC.
DISPOSITION: The patient tolerated the procedure well, stable to floor.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman who has had approximately two years of dialysis catheters. The most recent catheter had been placed in March. She presented with a bout of sepsis. The catheter fell out on its own, and her blood cultures now have been positive for 48 hours. It has been recommended that she have a new catheter access placed. It has also been recommended that she consider long-term dialysis access as well. Risks, indications, and techniques of catheter insertion were discussed. The patient understood and was agreeable.
1. Unable to thread wire into the right internal jugular vein and aspiration of the right internal jugular vein was difficult. Multiple attempts were made in aspirating this vein.
2. Tortuous course of the left internal jugular vein.
3. Left internal jugular venogram showed reflux into an anomalous vein; however, there was direct flow into the superior vena cava with the vein being widely patent. Postoperative chest x-ray pending.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and was identified as the patient. She was then placed supine on the operating room table, and LMA anesthesia was induced. She was prepped and draped in the normal sterile fashion using a PCMX prep. Multiple attempts at aspiration of the right internal jugular vein were made. The artery was inadvertently aspirated on two occasions and then eventually the jugular vein was able to be aspirated. However, a wire was unable to be threaded beyond 1-2 cm and continued to coil.
Therefore, conversion was made to a left-sided approach. Multiple attempts were made, but the vein was difficult to aspirate. Therefore, ultrasound guidance was utilized to aspirate the vein. The vein was identified and aspirated directly. The wire was placed. The wire anatomy was noted to be quite tortuous and the wire continuously wanted to thread into an anomalous vein. A 16 gauge Angiocath was then placed over the wire. Venogram was performed. A guidewire was then utilized to select the appropriate vein and course. The tract was then serially dilated, and the wire was exchanged back out for a J wire. The tract was serially dilated. Dilator and sheath were placed over the wire and the dilating wire withdrawn. The catheter was placed through the peel-away sheath and this was peeled away.
The position of the catheter was determined under fluoroscopy to be appropriate. Exiting site in the chest wall was determined. Tract was anesthetized. Catheter was tunneled appropriately. Both tracts were aspirated for blood and flushed without difficulty. The area was inspected. Hemostasis was adequately achieved with the use of pressure. A 4-0 Vicryl subcuticular stitch was used to repair the J wire site. A 4-0 Vicryl pursestring stitch was placed around the catheter and then this was sutured to the catheter. Appropriate dressings were applied. Postoperative chest x-ray was obtained. Results are pending at this time. The patient was transferred to the floor in stable condition.