This video captures a WavelinQ™ EndoAVF creation performed by Dr. Alejandro Alvarez, MD at SSM Health in St. Louis, MO. Vessel access was achieved in the brachial artery and a brachial vein while the endoAVF was created between the ulnar artery and medial ulnar vein.
Using ultrasound. The target vein for Venus access is identified in this case, the lateral brachial vein near the midpoint of the bicep has been selected for venous access acid is the larger of the two brachial veins. Local sedation is administered in the tissue surrounding the Venus access site. A sterile tourniquet may be applied to the patient's upper arm to aid in vasodilation during venous access under ultrasound guidance. A micropuncture needle is used to gain access to the lateral brachial vein. The ultrasound probe is carefully positioned such that visibility of the needle tip is maintained during venom puncture. Caution is taken to avoid damaging the median nerve with the access needle. Once the brio vein has been accessed with the micropuncture needle, a guide wire is introduced and access is confirmed under fluoroscopy. Next. A five French introducer sheath is placed into the brachial vein. It appears that the guide wire has been delivered from the brachial vein down the common ulnar vein and entered the entero vein using a guide catheter and Tuy burst sidearm adapter. A venogram is taken to confirm wire position and to visualize the Venus system. The venogram shows that the guide wire has crossed from the medial common ulnar vein to the lateral common ulnar vein and proceeds into theos vein. The target vein for this endo aVF creation is the medial ulnar vein. As such, the guide catheter and guide wire are pulled back, proximal to where the wire was crossing from the medial ulnar vein to the lateral ulnar vein. The wire is then re advanced into the medial ulnar 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 access location at 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 to the brachial artery. Visibility to the tip of the needle is again maintained as the needle is advanced through the tissue and into the lumen of the brachial artery. Caution is taken to avoid puncturing the median nerve with the access needle once confirmed that the needle is in the brachial artery. A micro axis wire is placed into the brachial artery. 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 such that it could interfere with the magnets in the wavelength endo af catheters. Later in the procedure. Next, the access wire is replaced with an 014 guidewire. An arteriogram is performed to make a visual assessment of the arterial anatomy using an angled guide catheter. The arterial guidewire is directed and delivered to the proper ulnar artery. The wires advanced at least 10 centimeters past the target endo aVF creation site to ensure adequate space for the delivery of the arterial catheter. Next, the CRM is rotated until it is positioned perpendicular to the target vessels. In this case, it is rotated in the caudal direction to achieve this view. This view is achieved when the guide wires appear to be at the greatest distance from one another. A second arteriogram is taken again to visualize the arterial anatomy. The arteriogram is then road mapped and a subsequent venogram is taken to completely visualize the arterial and venous system. In order to accurately choose the endo aVF creation site, the tip of the guide catheter is used as a marker and placed at the target endo af creation site. Next, 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, once the arterial catheter has been delivered to the target endo aVF creation site, it is rotated such that the backstop is facing towards the Venus guidewire with the rotational indicators being clearly visible with the arterial catheter. Now in position, the guide catheter is carefully removed from the Venus system. So as not to lose position of the Venus guidewire. Next, the Venus catheter is introduced while delivering the Venus catheter over the 14 guidewire. Care is taken not to kink the distal portion of the catheter. The Venus catheter is advanced over the 14 wire until the yellow hemostasis valve crosser encounters the hemostasis valve of the introducer sheath. The yellow valve crosser is inserted through the hemostasis valve until it stops at the hub of the sheath. Once through the hemostasis valve, the cat continues to be advanced through the sheath and the yellow valve crosser is retracted to the proximal end of the Venus catheter. Before the magnets of the Venus catheter engage with the magnets of the arterial catheter. The Venus catheter is rotated such that the electrode is directed towards the arterial catheter. Once it is properly rotated, the Venus catheter is further advanced and delivered to the endo aVF creation site. Notice the catheter's co aft once are in proximity of one another, 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 compression of the electrode against the backstop, the consistent space between the magnets in 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. During wire removal, extra care is taken to ensure catheter position is maintained and alignment is not lost. Performing this step under fluoroscopy helps ensure this does not happen. 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. Prior to activation, the device is then activated by pressing the yellow button on the electrosurgical pencil until the tone stops. When the activation cycle is complete, the space between the electrode and the backstop previously occupied by the tissue is no longer visible. This indicates that the endo af has been successfully created with the activation complete. The venous and arterial catheters are removed. The Venus catheter is removed first to allow outflow from the newly created endo af. A fistulogram is performed through the arterial sheath confirming the endo af 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 the deep Venus system. A final fistulogram is performed to verify endo af flow following brachial vein embolization. This fistulogram shows the flow coming from the brachial artery into the common ulnar artery across the endo af into the medial ulnar vein. Blood then flows from the medial ulnar vein to the lateral ulnar vein via bridging veins and through the perforating vein to the superficial cephalic and bacill veins.
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