POF 2015

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Case 1Thrombosed brachial artery

Situation

• 35 y/o male

• Thrombosed LUA AVG

• Had a long-standing AVF ligated 1 ½ year ago

• Weak radial pulse

Angiogram of AVG after severalsweeps with Fogarty

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Brachial artery very largecaliberLarge thrombus in artery

Brachial artery very largecaliberLarge thrombus in artery

Brachial artery very largecaliberLarge thrombus in artery

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BifurcationThrombus stops at level ofanastomosisForearm arteries normalsize and no thrombuspresent

Question 1

• Should thrombectomy be performed in free-standing out-patient facility?

A. Yes

B. No

Question 2

• What is the most probable explanation for thethrombus formation in this case?

A. Simply a case of clot extension into the artery

B. Related to stasis of blood flow secondary tosudden cessation of high flow in large dilatedartery

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Question 3

• How would you approach this problem?

A. Use thrombolysis

B. Use Thromboaspiration

C. Refer to surgery

Question 4

• If you were able to restore flow to access, wouldyou place the patient on long termanticoagulation?

A. Yes

B. No

Diameter of Brachial Artery

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Effect on Flow Velocity

• Arterial diameter• Normal subjects - 4.36 + 0.13 mm

• Hypertensive subjects – 4.97 + 0.13

Safar, ME, et al. Circulation 63, 393-400, 1981.

Case 2Subclavian-Subclavian AVG Thrombosis

Situation

• 63 Y/O male

• Hypertensive

• Bad PAD – amputation of fingers, amputation oftoes

• Recurrent access problems – frequent clotting

• Los of access sites

• Currently has left subclavian-subclavian loop AVGon chest

• Referred for thrombosis

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Still image from angiogram

Arteriogram

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• During the procedure the patient began tocomplain of headache and his BP went up to200/150

• Otherwise was doing OK, talking respondingappropriately

• Procedure was discontinued, venous outflow hadnot been opened

• Patient was sent to hospital

• At hospital the patient had a CT scan that wasnegative

• Next AM was doing well visiting with family

• Sudden onset of obtundation

• Intubated

• Had repeat CT scan – negative

• MRI was done – showed cerebellar infarct

• Herniated – neurosurgical decompression

• Patient expired

Question 5

• Would you have discontinued the case at this timeor continued and opened venous outflow?

A. Yes

B. No

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Question 6

• Do you think terminal episode related to procedure

A. Yes

B. No

Case 3Clot in Central Veins

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Situation

• 37 year old female with clotted left upper arm graft

• A dialysis catheter was removed from right IJ about2 weeks ago

• No prior procedures performed on this access

• The graft was canalized and a 5-F catheter wasadvanced easily to the central vein and contrastwas injected

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Question 7

• How would you manage this case?

A. Thrombolytic

B. Stent/stent-graft to exclude thrombus

C. Thromboaspiration

D. Refer to hospital for management

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Case 4Catheter Dysfunction

Situation

• Left IJ Tesio catheter (23 and 25 cm: right sidedstandard length) with exit sites bleeding.

• On Fluoroscopy, the Tesio tips are lodged in thejunction of the left innominate vein and the SVC.

• Poor Tesio function; resistance to both ports.

• Tesio ports pulled out on 2 wires in preparation fornew longer 27 and 30 cm Tesio port insertion.

• Venous port inserted with tip to RA.

• Arterial port would not advance; its tip stuck at midleft innominate vein.

Situation

• Dialysis patient is catheter dependent

• Dialysis with left sided Tesio catheters

• Referred because of bleeding around exit sites

• On fluoroscopy the catheter tips are atbrachiocephalic-SVC junction

• Catheters flushed – resistance

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• Guidewires were inserted in preparation forexchange

• Venous catheter was inserted and passed down tolevel of atrium

• Arterial catheter would not advance beyond thebrachiocephalic-SVC junction

• Catheter removed

• Radiocontrast injected to visualize anatomy viaarterial tract

Obstruction atbrachiocephalic-SVCjunctionRadiocontrastrefluxing up cathetertunnel

Angioplasty ofstenosis with 12mm balloon

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Radiocontrastinjection of arterialcatheter tunnel

Question 8

• The flow is passing through a collateral vasculartract, what do this vessel(s) represent?

A. Normal vessels that have become dilated

B. The formation of new vessels secondary to theobstruction

Question 9

• What would you do at this time to obtain a workingcatheter for this patient?

A. Dilate the venous tract and insert a single bodiedcatheter

B. Evaluate the opposite side

C. Use the venous passage for the arterial catheterand return blood to the collateral site

D. Leave the venous catheter where it is and placethe arterial catheter through the collaterals

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Case 5Ischemic monomelic neuropathy

History

• The patent is a 63 year old diabetic female

• On dialysis for 1 year

• Has a brachial-cephalic AVF

• Experienced ischemic monomelic neuropathy attime of creation

• Regaining some use of hand• Can almost make a fist• Still very weak

• Recurrent cephalic arch stenosis

• Has been treated with PTA at 4 month intervals

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Physical Examination

• Left hand is cold

• No pain

• Atrophic changes of nails

• Muscle wasting

• Ischemic changes at finger tips

• Weak thumb apposition, ape hand deformity (mediannerve)

• Weak wrist extension (radial nerve)

• Poor function of the intrinsic hand musculature (ulnarnerve)

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Day after accesssurgery PAIprocedure wasperformed

Angiogram

Lesion

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Post-PTA

Additional Information

Patient has a good basilic vein

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Question 10

What would you do at this time?

A. Continue with PTA of cephalic arch q4 months

B. Place a stent/stent-graft

C. Out-flow relocation

D. Create brachial-basilic AVF

E. Evaluate opposite arm for AVF

Case 6Cephalic Arch Stenosis

Patient with brachial-cephalic AVFReferred for decreased flow

Has had recurrent cephalic arch stenosis

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Difficult PTAUltra-high pressure balloon required

Lesion dilated

Post treatment angiogramGood flow

Small extravasation, stable

Question 11

• What would do at this point?

A. Nothing

B. Balloon tamponade

C. Stent/stent-graft

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Case 7Thrombosed AVG

Situation

• 68 y/o male on dialysis 4 years

• Has a upper arm AVG

• Referred for thrombosis of graft

• Hypertension

• Chronic smoker

• Left leg amputation

• Doing well on dialysis

Thrombectomy Procedure

• Thrombectomy performed without difficulty

• Had venous anastomosis stenosis – treated withoutproblems

• Flow restored

• Had arteriogram performed

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Question 12

• Should arterial anastomosis be treated?

• A. Yes

• B. No

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Question 13

• If you knew that patient’s left hand was cold incomparison to right, would you treat lesion?

A. Yes

B. No

Case 8

Recurrent catheter dysfunction

History

• 68 y/o male

• Catheter dependent

• Recurrent flow problems

• Catheter changed 3 times in 10 days for poor flow

• No apparent explanation

• Problem is persistent• Multiple tip positions

• Multiple tip orientations

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Catheterappearance

Question 14

• What would you do at this point?

A. Use a fibrinolytic lock between dialysis sessions

B. Insert a shorter catheter an position tip aboveSVC-atrial junction

C. Insert a longer catheter and place tip in inferiorvena cava

What was done

• Decision made to place catheter tip in inferior venacava

• 55 cm catheter used

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Finalcatheterposition

Catheter tip

Follow-up

• Catheter functioned well

• Dialysis unit told to reverse lines

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Case 9Unusual structure above diaphragm

• A 79 year old female with history of Carcinoidtumor presented with immature right upper armfistula

• During fistulogram, a Roadrunner guidewire wasused

• There was slight difficulty crossing the diaphragm,the soft tip of the guidewire was coiling in the rightatrial area

• A catheter was advanced over wire and contrastwas injected

First contrast injection

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Second contrast injection

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Third contrastinjection

Question 15

• What is structure in question?

A. Artifact

B. Subintimal injection of radiocontrast

C. Result of cardiac perforation

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Answer

• Images shown to several IR – consensus was that itrepresented an subintimal injection ofradiocontrast

• Cardiac perforation is arecognized complicationof central venouscatheter placement

• Generally fatal• May be acute or delayed

• Acute generally relatedto dilator or use ofacute catheter that istoo long

• Chronic related tocatheter tip erosion

• 7 cases of guidewireperforation have beenreported in the literature

• 5 related to straightguidewire

• 3 related to J-tip guidewire

• Most have been fatal

• 2 occurred during catheterexchange

• 1. Blake, PG, et al. Int J ArtifOrgans 1989; 12:111.

• 2. Cavatorta, F, et al.Nephron 1998; 79:352.

• 3. Lee, YM, et al. ClinNephrol 2009; 72:220.

• 4. Khan, IH. Postgrad Med J1991; 67:591.

• 5. Quinn, MP, et al. NephrolDial Transplant 2006;21:2669.

• 6. Hiroshima, Y, et al. InternMed 2012; 51:2609.

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Case 10Recurrent DASS

History

• 35 y/o diabetic

• On dialysis for several years

• Left brachial-basilic AVF

• History of DASS

• Had DRIL procedure

• Has started having pain in hand on dialysis

Physical Examination

• Left hand is cold in comparison to right

• No radial pulse at wrist with AVF open, nonoticeable change with AVF occluded

• Weak radial Doppler at wrist with AVF open, nonoticeable change with AVF occluded

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Angiogram of Access

Question 16

• What is most likely explanation for symptoms?

A. Occlusion of revascularization by-pass

B. Progressive arterial disease

Angiogram of Access

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No flow to lower arm through by-pass

By-pass anastomosis dilated with 6 X 4 angioplasty balloon

Good flow through by-pass graft after the PTA

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Diffuse arteriopathy of forearm arteries

Comments

• Occlusion of the by-pass portion of the DRIL is adefinite risk with this procedure

• For this reason many surgeons do only the DRportion of the DRIL , omitting the IL and the needfor the by-pass

Case 11Stent Migration

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History

• 56 y/o male

• Dialysis for 2 years

• Loop graft in left forearm

• Double drainage• Cephalic & basilic

• Referred for poor flow

Situation

• Venous anastomosis stenosis – 80%

• Dilated with 8 X 4 angioplasty balloon

• Lesion elastic - 20% residual

• Decision made to place flare stent at anastomosis

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Stent is partially blocking basilic vein

Question 17

• What would you do at this point?

A. Refer to surgery for stent-graft removal

B. Reposition stent-graft using angioplasty balloon

C. Leave it as it is since there is double drainage