Chapters Transcript Video Radial EndoAVF Creation Using the WavelinQ™ EndoAVF System This video captures a WavelinQ™ EndoAVF creation performed by Dr. Alejandro Alvarez, MD at SSM Health in St. Louis, MO. Duration: Approximately 10 minutes. A sterile tourniquet is applied to the patient's upper arm to aid and vasodilation during venous access. Using ultrasound. The target vein for Venus access is identified in this case. A brachial vein near the midpoint of the bicep has been selected for Venus access. Local sedation is administered at the Venus access site under ultrasound guidance. A micropuncture needle is used to gain access into the lateral brachial vein. Caution is taken to avoid damaging the median nerve with the access needle. Once the brachial vein has been accessed with the micropuncture needle, a guidewire is introduced and access is confirmed under fluoroscopy. A five French introducer sheath is then placed into the brachial vein and the access wire is replaced with an 014 guide wire using a guide catheter and a Tuy burst sidearm adapter. The guide wire is advanced toward the target endo aVF site. A venogram is taken from the guide catheter to visualize the deep venous system, perforating vein and its connections to the superficial system. This venogram confirms that the target endo aVF creation site will be between the radial vein and the radial artery. The venus wire is advanced into the medial radial vein beyond the target endo aVF creation site. This provides adequate wire purchase to position the venus electrode at the desired creation site. Next, the target arterial axis location in the brachial artery is identified under ultrasound brachial artery. Access is gained slightly peripheral to the venous access to provide adequate hemostasis management. Post procedure, local sedation is administered at the chosen arterial access site. Here, sedation is injected around the median nerve bundle and is also injected such that the fluid pushes the median nerve away from the path the needle will take to the brachial artery. This helps to ensure the median nerve is avoided during arterial access under ultrasound guidance. A micropuncture needle is used to gain access into the brachial artery. Visibility at the tip of the needle is maintained as the needle is advanced through the tissue and into the lumen of the brachial artery. Caution is again taken to avoid puncturing the median nerve with the access needle once confirmed that the needle is in the brachial artery. A micro access wire is placed into the vessel. A five French introducer sheath is then placed into the brachial artery. Care is taken to ensure the tip of the arterial sheath is not inserted too far. Next, an 014 guide wire is delivered to the radial artery. Again, the tip of the wire is positioned at least 10 centimeters beyond the target endo aVF creation site to ensure adequate length for the wavelength catheters. An arteriogram is performed to assess appropriateness of vessel anatomy for the procedure. As mentioned earlier, it was decided that the target endo aVF creation site would be in the radio location between the medial radial vein and the radial artery. Another venogram is performed through the guide catheter to visualize the venus anatomy and to approximate the location of the target endo aVF creation site. The sea arm is rotated until it is positioned perpendicular to the target vessels. In this case, it is rotated cranial to achieve this view with the C arm in a view that is perpendicular to the target vessels. A final venogram is taken to confirm the location of target endo aVF creation site and to see how it communicates with the perforating vein and the rest of the superficial system. The arterial catheter is delivered to the target endo aVF creation site care is taken while the catheter is inserted into the hub of the sheath. So as not to kink the magnetic portion of the catheter, the arterial catheter is delivered to the target endo AF creation site with the backstop facing towards the Venus guidewire with the rotational indicators clearly visible. In this case, the tip of the guide catheter has been positioned at the target endo aVF creation site and used as a reference for arterial catheter positioning next, the guide catheter is removed and the Venus catheter is introduced through the Venus introducer sheath before the Venus catheter is delivered to the target creation site. It is rotated such that the Venus electrode is directed towards the arterial catheter. Once it is properly rotated, the Venus catheter is delivered to the endo aVF creation site. Notice the magnets in the Venus and arterial catheters coapt as the distal magnets in the Venus catheter reached the proximal magnets of the arterial catheter. The Venus catheter is advanced until the arc shaped electrode matches up with the arc or saddle of the backstop proper alignment is visualized via the open appearance of the proximal and distal rotational indicators on the catheters. And by the visible gap between the electrode and backstop, the space between the magnets and the catheter indicate the distance between the catheters is within the one millimeter maximum distance requirement. Once catheters are in position and properly aligned, the arterial and venous wires are removed. This is done to ensure they do not impede on proper catheter alignment and to ensure they do not come into contact with the electrode during activation, the Venus catheter is reciprocated to observe electrode compression against the peaks of the arterial backstop. This provides further visual indication that catheters are properly aligned. The electrode is then re centered over the backstop. The device is then activated by pressing and holding the yellow cut button on the electrosurgical pencil until the activation stops. When the activation cycle is complete the space between the electrode and backstop previously occupied by tissue is no longer visible. This indicates that the endo aVF has been successfully created. Next, the venous and arterial catheters are removed, the Venus catheter is removed first to allow outflow from the newly created endo aVF. A fistulogram is performed through the arterial sheath confirming the ENDO aVF has been successfully created. An embolization coil is placed in the brachial vein used for Venus access just distal to the end of the introducer sheath. This helps divert additional flow to the superficial system to support maturation of the vessels to be used for dialysis access. In this case, a second coil was placed to further ensure flow was prevented from returning through a brachial vein. A final fistulogram is performed to verify endo aa flow following brachial vein embolization. This fistulogram shows the flow coming from the brachial artery into the proximal radial artery across the endo af to the medial radial vein into the perforating vein and out through the cephalic vein, the venus and arterial shees are removed and puncture site, hemostasis is gained using manual compression. Published September 5, 2024 Created by Related Presenters Alejandro Alvarez, MD Internal Medicine, Nephrology, Radiology View full profile
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