Dr. Richard DeMasi (VS) In treating a patient with pacemaker, upper arm loop arteriovenous graft, proximal subclavian stenosis and several interventions, Dr. DeMasi uses the Atlas balloon to perform angioplasty and will confer with Cardiology on using a covered stent.
There's a, a convoluted story which demonstrates these patients can get quite complicated. This, uh, patient had a, uh, left upper arm brachial actuary vein bucket t configured a V graft done in uh July of 2019. She has a pacemaker on that side, got a swollen arm has a stenosis in her subclan that's been dilated several times. She also had steel symptoms for that reason. She got proximal to the axillary artery. So she has an effect. Now, an upper arm loop, a graft. Um, she has had the proximal subclan dilated at least twice, maybe three times and comes in now with, uh, poor functions. Um, I have some angst about putting a stent across, uh, pacer wires. Um, uh, usually we just balloon that, but I think if she's gonna keep this as her access, we may have to give some consideration to putting a stent across there, pinching the burn deer. It's dumb messing going in. Ok. So there's a nice brisk flow, but you see retrograde flow going down that, uh, brachial vein there, which means we got something more proximal for sure. Doesn't have a whole lot of arm swing to be honest, but definitely something going on here with this Pacer wire was really right where it crosses a clavicle. Yeah. So that a little bit more central. So that snow is in the same place. So we have a 12, 4 Atlas uh balloon. So that those in the same location as it, as it was uh previously without a Pacer Wire there and somebody being Pacer dependent, I'd put a stent across that thing right now. But we're just gonna balloon it today and then confer with our cardiology colleagues. I think to see how they feel about us. Putting a cover stint across that piece of wire. I think we could probably do it, but I'd probably do it in a setting where we can um externally pace in a hospital setting if we had to. Ok. What about there? You feel a little pressure under your collar bone? Save that image right there. OK. Down, take a breath in for me. Blow it out and now just hold your breath. Don't breathe, don't move, hold very still, don't breathe, don't move, hold very still. Pretty good. OK. Let's go back and look at this. Can you bring the I I out a little bit Marky and let's just look at this Venus outflow, let's make sure. So this is the same shot. We're gonna see if there's, I'm gonna see there's retrograde flow going down that break. You can see the retrograde flow. The bra is now gone. Which means we've humanly fixed the problem up top. Um, I don't really see the venous emos all that. Well, uh, the graph has a great thrill. I don't think that's an issue, but I'm gonna see if I can include it. Marky Mark. I'm gonna get you to turn this. I, I, maybe this away while, while I'm puffing some contrast in there a little bit more. I don't think there's an issue there. You see that through a run mark? Yeah, that's the proximal segment really looks quite good. I don't see a problem in the graph. I think we're good. Uh Stitch. I think what I'll, I'll dictate my note that if we do, if we have a proximate outflow problem again, that we do it in a hospital setting and consider stinting that uh Subclavian uh with a covered stent. I think that'd be the next move. OK. So that's a um uh left arm, maybe fish gram plasty of a left subclavian stenosis uh in the presence of a pacer wire. I think if this occurs again, I think it's a, it's a good graph that's worth salvaging. That I would consider putting a stent across that with some cardiology support and blessing on that and do it in a setting where you could temporarily pace if you had a problem with the pace or wired relative to the stent, which I don't think is gonna happen
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