Dr. Samuel Steerman (VS) treats a patient with an brachial axillary AV graft and thrombosis, resulting in no peripheral access. To open the vessel, he utilizes the Conquest PTA Balloon Dilatation Catheter to aid in breaking down the thrombus.
We have a seven year old male with a thrombosed access. He has a brachial axillary V graft. It was placed about nine months ago. It's had two interventions with stenting of at least near or in the venus anastomosis and he has thrombosed it today. He also has no peripheral access. So the first thing we're going to do for the sake of efficiency is we're going to place our first access. We're going to start delivering his sedation and his heparin. And then we're going to talk about our plans for the case. Sir. I have some numbing medication here. You'll feel a little stick in a sting whenever I'm numbing for thrombectomy. And I'm expecting to place a second access. I will numb both at the same time for efficiency. Ok. Gonna feel the access, get a mind's eye of where it is. Sometimes I'll stabilize it between two fingers. Sometimes I'll, it's not going to bleed. Ok? And maybe this will work. Sexist is a tad on the deeper side, but we got the wire to go. Ok. Put our seven in. Um, can I have a 65 bear if we're gonna gives, uh, medication Um, so we need to get central, uh, Venus access to be able to give medication. It's a bit of a larger lumen. Well, that crossed very easily. Ok. While we're here, we can get our central shot. This will also confirm that we actually are within the Venus system and not in the arterial system. Ok. So let's hook up here. Roll forward, please. Ok. We're gonna give sedation. We're gonna give antibiotics. Um, And for all my thrombectomy to give 5000 units of heparin. Um And that's what we'll do right now. Um I think it's worth to do this Venus shot, uh to make sure you're in the Venus system know which way the grafts go. Um, particularly in the upper arm axillary loop. Sometimes they can be one way or the other. Um And there was a trainee of ours that put a 12 millimeter balloon into the subclavian artery. Um, and cause more trauma than she was anticipating. All right. So we're giving the medication, um, while we're doing this, I wanna show you what we have on the field. Um Because uh thrombectomy can be complicated there, there can be a lot of things going on. So I try to standardize the things that I can control before we even start. First thing we have is a seven front sheath. We have a six front sheath right here. This is gonna be on the Venus limb of the graph directed towards the arterial uh limb. We have 1/4 or a catheter. This is a non over the wire. It is, um, not over the wire. It's just past, um, plain uh without being over the wire. And then there's an eight by eight balloon. Um, we're performing this on a six millimeter graft. So the eight millimeter balloon is our workhorse. That's what we're going to use to help macerate the Thrombus. This is the, the standard working things as well as the inflator. So everything is ready to go. Have we given all the antibiotics and sedation. Ok. Um That way we don't have to think about things. We don't have to wait for things and any more time that we spend in the lab, things start to degrade, imaging starts to degrade, access, starts to degrade our patients, start to degrade, um, in, in some situations. So we want everything set up for success here. Um As soon as we get, um, as soon as we get, um, all of our antibiotics and sedation and we're going to proceed with the next step. All right, our medication is in and we're, we're essentially gonna lose IV access here for a second. Um, as we do what we need to do, this is our Benson wire or working wire, move this back over so we can see everything great. All right, our wire goes centrally. Um And now we're gonna use our eight millimeter balloon. This is our eight by eight I don't recommend using an eight by four, because this will cover more distance. It will be a more efficient procedure. Ok. I'll hook up the end of later. Um, we use the balloon now to macerate the thrombus, we're gonna do it from a peripheral to central direction. So I pulled my sheath back just to uh the puncture site and we'll pull the balloon back as well. Get an invite. Um, some people will use TP A um in situations like this. Um I don't find it to be all that helpful. Um Lisa is doing what I want her to do without telling her she's inflating and then deflating, inflate again. And we're macerating the thrombus and as the balloon comes down, I'm gonna give forward pressure on this to push any of that Thrombus forward. Yeah, into the Venus system. Go home. So that, that really wasn't too much trouble to do this. I don't know the TP A would really um improve that process. The uh the one caveat to that is if you are doing a thrombectomy on a uh fistula and you have some aneurysmal areas, um It's not gonna be a six millimeter lumen. Um And you want to get into those nooks and crannies to break things up. Um Then TP A can be helpful, then you can get very creative with some of the devices that work like egg beaters to try to break up some of that. Thrombus graphs are much easier access ways. Graphs are much easier um to uh treat percutaneous thrombectomy for than fistulas. In fact, to the point where um we really, I personally try to not do percutaneous thrombectomy on fistulas. So we assume that we've cleared our outflow right now. So we're going to be placing our second sheath directed towards the arterial limb and this, this can be a little bit challenging to place some of these sheets. Um, a, a good bailout maneuver. This one happened to pass. Um If you're really stuck in a situation is to bring your balloon to the area that you want to access. If you really can't feel the balloon, if you really can't feel the graft inflate the balloon, you can feel the balloon usually and then stick your needle in through the skin and puncture the balloon. Um, and that will get you within the graft. Um You'll just have to pull another balloon when you're finished. Ok. We've got access. Now, very important thing to do is not flush any of these sheaths. It's second nature to want to flush these and we don't want to do it because it can pop some of that clot into the artery. Can we take the stiffening wire out? Please usually try it without the stiffening wire first. And uh and that just happened to pass on the first time around. This is a three CC syringe. I find this very helpful, use a three cc syringe versus a tuberculin syringe because you can screw this on. And when you screw this on place, you can pull from here versus a slip tip or a tuberculin syringe, you won't be able to pull. Now, we'll see under X ray. We've got our Fogerty in the proxy in the mid brachial artery. We're going to pull it down as we're inflating it and then usually get some resistance to the arterial nomos, it not much here. And we're gonna continue to drag it through till we get here, gonna pull negative on the syringe and let's judge the success. Ok. We got some blood there. Maybe some clots stuck in. Ok. Let's drag it again. If, um, if for some reason, we couldn't get this to pass into the artery, sometimes I'll do external manipulation to try to get the, uh, the Fogerty either around the sheath or through the anastomosis. Um Another thing you can do is advance a sheath across the anastomosis and then in a buddy wire fashion, um, you can pass the non over the wire Fogerty. Um, really are very few situations where I find it helpful to use an over the wire Fogerty. Yeah, a little bit of flush. It's a little bit deep. So I'm not quite sure what I feel. All right. So you can see we've got pulsatile inflow. Now, there's, there's multiple goals that we need to perform in this procedure, but one of them is to assess the adequacy of the inflow that's adequate inflow. I just assessed it by looking at the pulsatile flow that was coming through there. You can take a picture if there's any residual clot, um then you could shoot it down the arm. So if I have pulsatile flow like that, I consider the inflow adequate. Can I have a monochrome, please? I'm gonna take out the sheet. Now, um that way we don't have a uh flow limiting structure within the graft. Um If there's residual clot in there, uh this won't get in the way as I do other interventional maneuvers to try to remove that clot, still haven't injected anything into the sheaths. Paul, please. Hm This sheet, I bet if I pulled on it, I'll get blood as well. Yeah. So we've got good blood flow there. Ok. So we know the artery is open. It has a weak thrill to it. No, I take that back. It has a nice thrill to it. I still am not sure that the outflow is clear. So what I'm going to do is inject some contrast but but not, not the full push that I'll often do just a light injection and I see all of it is going central. So that's fantastic. So we know that there's no outflow. We know that there isn't going to be a venous obstruction that's gonna reflux contrast into the artery and potentially send a clot um down distally So now I'm going to take a better picture. Ok. Much better picture. We see uh, little leak where my sheath was in and that's fine. Looks like the Venus anastomosis looks wide open. I don't see a problem there. Maybe there's some residual thrombus in the axillary vein. Let's take some more pictures. That's what you do when you're not sure what to do. Yeah. So there's some residual thrombus in there. Let's bring this eight millimeter balloon back in. Um, we may need a larger balloon to clear this thrombus. Oh, yeah, inflate, please. Now I'm gonna show you an advanced move here. Ok. Come on down. Yes, go on. You're open. We're going to give a little bit more sedation. All right. So that cleared it. Um, we could have also used a, uh, 10 millimeter balloon to try to alleviate some of that thrombus. Um, but ii, I think it looks real good there. I'm not seeing, um, I'm not seeing a definitive cause of this thrombosis which is a, a little bit disconcerting. Um, you know, there's, there's two goals of the procedure. One is to clear the thrombus, the one and the second goal is to figure out what caused the thrombus and prevent it from happening in the future again. So we have a nice thrill in here. We're not seeing, uh, any stenosis. I'm putting a little bit of pressure, um, where we see that, uh, little area of extravasation, I think that was from where my sheath was. Um, when I, when I push real hard it, it goes into there. Um, let me image the Venus Lim again. Yeah, there isn't, there isn't really a narrowing right there. We've cleared it out. I think the stent is in proper place. I don't think the stent is causing stenosis. We'll shoot one image looking centrally again to check our outflow really just looking for an area of stenosis, something that requires balloon angioplasty or stenting. And, and we're not really seeing that which, which can happen from time to time. Sometimes it's due to hypotension, sometimes it's due to hypercoagulability, maybe some external pressure caused it. But we've imaged this what I consider to be completely even though we haven't imaged the arterial limb. I don't feel that that is the source and with that, we're going to complete our procedure. Is it OK? If I take out your IV? OK. Thank you.
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