PREOPERATIVE DIAGNOSIS:
Clotted arteriovenous graft of left upper arm.
POSTOPERATIVE DIAGNOSIS:
Clotted arteriovenous graft of left upper arm.
OPERATION PERFORMED:
Removal of AV graft, left upper arm, and repair of brachial artery with end-to-end anastomosis.
SURGEON: John Doe, MD
ANESTHESIA:
MAC.
DESCRIPTION OF PROCEDURE:
With the patient on the operating table, in supine position, the left arm to her side, was sterilely prepped with Betadine from hand to the axilla and draped. Marcaine 0.5% without epinephrine was used for local anesthesia. The old arterial incision was opened and extended medially and distally slightly. The dissection was carried through the subcutaneous tissues with electrocautery and needle-tip Bovie. The proximal artery and distal artery were then dissected out and controlled with vascular loops. The graft was dissected free and then bulldog clamps were placed across the artery proximally and distally, and the graft was opened in the transverse direction about 5 mm beyond the anastomosis.
Thrombus was removed from the anastomotic area, and using another #3 Fogarty, the Fogarty was passed proximally and distally in the artery, and no thrombus or clots were found in the artery. The graft itself was then declotted using Fogarty catheters. However, we were not able to pass the catheter through the anastomosis. Therefore, we felt that we needed to open the venous end, but prior to doing that we went ahead and closed the arteriotomy and the graft with interrupted 6-0 Gore-Tex sutures. The bulldogs were then removed from the artery, reestablishing flow to the hand.
Next, the old incision in the axilla was opened and the graft identified and traced down to its venous anastomosis. There was a fairly intense inflammatory response around the graft, and there was a thick sheath around the graft that, when incised, actually was not adherent to the graft. There, however, was no evidence of purulent exudate present. We did culture the graft at this location and then attempted to dissect out the proximal vein. This, however, was difficult as there were several bundles of the brachial plexus around this vein and we decided to abandon dissecting directly on the vein more proximally and instead opened the graft to try to do a thrombectomy of the graft through the graft itself.
A longitudinal incision was made on the hood of the graft, but we were only able to pass at most a 1 mm dilator through the anastomotic area. We were also able to pass a #4 Fogarty through this area, but it would only go up 5 cm to at most 10 cm, and on attempting to deploy the balloon, it was apparent that this proximal vein was actually entirely sclerosed. Therefore, we had to abandon the revision and thrombectomy of the graft and decided instead, since the graft did not seem to be well healed even at the venous end and may actually be infected, to go ahead and remove the graft. The graft was then cut from the venous anastomosis, and the vein itself was oversewn with the 3-0 Vicryl suture to prevent any backbleeding. The arterial end was then exposed once again. The graft artery anastomosis was excised, leaving an end-to-end portion of the artery for reanastomosis. The artery was mobilized proximally and distally and then end-to-end anastomosis was performed with running 6-0 Prolene sutures.
On release of the bulldog clamps on the artery, there was good flow reestablished through it with no leakage. The artery was wrapped with Surgicel for security purposes and then the graft itself was removed from the tunnel by stripping the tissues away from the graft, and actually just with gentle traction, it broke free of its attachments, again making it suspicious that the graft may have been actually infected. The tunnel was then packed with half-inch iodoform gauze just as a thin ribbon and both ends being brought out through a counter incision in the mid portion of the graft, so that the tunnel itself would be allowed to drain if need be.
The wounds were then closed after irrigating with antibiotic solution. A 3-0 Vicryl was used for the subcu and the axilla, running 4-0 Vicryl subcuticular with Mastisol and Steri-Strips, antecubital area. After subcu was closed, nylon sutures were used in a running fashion for the skin closure. A small counter incision in the mid portion of the graft was left open, and the two ends of the gauze were pulled through it. Sterile dressing and bacitracin ointment on the antecubital incision and gauze and Kerlix was applied. The patient tolerated the procedure well. Estimated blood loss was about 25 mL.
