Morbidity and mortality By: Hanaa Tashkandi Surgical resident KAAU

history MRN Consultant:professor Wali Cause of morbidity: unplanned returned to OR: embolectomy left arm for clotted left arm AV fistula. Date of admission : Date of discharge :

a 54 year old yemani male patient. known -ESRD on regualr HD. -DM on -status post primary failure of the left arm transposed basilic arteriovenous fistula. -Right subclavian vein thrombosis.

Past surgical history In 2006 : the patient had a permacath and HD was established. One month later: it was blocked. Then: The patient had a right AVF Goretex graft (as the cephalic vein was found to be rod like and obliterated) Later on: It was clotted. So the patient continued the hemodialysis thruoght a permacath. 6 months later : The patient admitted again for declotting, Which was successful but unfortunetely it clotted again.and the patient developed hematoma at the site of declotting..

So the patient was investigated and right upper extemity venography was done : which showed severe central stenosis involving the junction of the right subclavian and innominate veins. After that: central venopraphy and attempted angioplasty but unfortuenetley it failed as the stenosis was very severe and the smallest 4F catheter could not be placed across the lesion.

So the plane was to create a new AVF in the other side. After that, the patient underwent evaluation of the left side venous system. Left arm venogram done: Which showed not good veins noted in the left forearm. The cephalic vein was not opacified even in the upper arm. The basilic vein is patent. The axillary, subclavian and innominate veins are patent to SVC..

so the patient had: Primary left transposition of basilic arteiovenous fistula creation. Post operatively it became weak and the blocked.

So the patient admitted electively on for left arm straight graft. Physical examination: -Within normal. -Limbs: non functioning right forearm AVF with no thrill most likely blocked. -Bilateral palpable radial and ulnar pulse.

laboratory 5\4\2007 CBC: WBC:7.28 HB :11.8 PLT :215 PT:12.8 PTT:31.3

Electrolyte: Na 136 K 6.8 Cl 108 PO BUN 6.8 Creatinine 136

Protein S free 0.84 N Protein S total 0.99 N Antithrombin III 137% H Protein C electrophoresis 1.03 N APC resistance N

At the end of anastomosis, there was no bleeding, good thrill over the graft with good distal radial artery pulse. But on the same day, it was blocked again

Next day the patient returned back to OR for thrombectomy. intraoperatively: Clotted left arm straight graft. The clot was found mainly at the site of anastomosis and progressing proximally inside the graft.there was no bleeding. Heparin infusion was started and warfarin.

On follow up visits: the fistula was functioning well. permacath was removed. - 6 months later, the patient presented to the ER with non functioning AVF again. - Referred to nephrology were he referred to have U\S: - The left AVF showed loss of normal colour Doppler with evidence of intramural echogenic thrombus starting from its proximal aspect until the antecubital region where it join the brachial artery. - Otherwise, the deep veins and arteries are patent with no evidence of thrombosis.

After that, successful dialysis graft thrombolysis and angioplasty. There was also evidence for central venous stenosis in which it responded nicely to ballon angioplasty.

Thank you

Physical examination Generally: Patient is conscious, oriented, not pale or jaundice. No lymphadenopathy. Vitals: normal. Chest : clear, equal air entry, vesicular breathing no added sounds. Abdomen: soft and lax no organomegaly.

Protein C electrophoresis 1.03 N Protein S total 0.99 N Protein S free 0.84 N Antithrombin III 137% H APC resistance N

In 20\6\2007 The pt was operated. Left arm straight graft was done. Intraoperatively: Good brachial artery with peripheral adhesions secondary to the previous operation. Some subcut. Edema of the left arm.

radiology Right upper extremity venography (17\4\2007). To evaluate the venous system for AV dialysis access creation. No good cephalic vein seen in the forearm. Widely Patent basilic vein. The axillary and subclavian veins are patent. Tight stenosis involving the junction of the right subclavian and innominate vein with collateral vessels.

Central venography and angioplasty. (30\4\2007) Very fibrosed right innominate vein with large collateral vessels indicating the chronicity of the occlusion. Angioplasty was not performed because even the 4 F catheter could not be placed across the lesion.

Left arm venogram (29\5\2007) No good veins noted in the left forearm. The cephalic vein is not opacified. The basilic vein is patent. The axillary, subclavian and innominate veins are patent to SVC.

Good brachial vein close to the axilla proximally. So: Dissection of the artery done. Exposure of the brachial axillary vein. Gortex graft used to anastomose the axillary vein to the brachial artery.

Flushing with heparin saline proximally and distally. Wounds were flushed with antibiotics.

Post operatively At the end of the anastomosis,there was no bleeding, good thrill over the graft with good distal radial artery pulse.

So the patient was operated again on 21\6\2007. Because of thrombosed left arm straight graft. Left arm graft thrombectomy under local.

intraoperatively The clot was mainly at the site of anastomosis and progressing proximally inside the graft. There was no bleeding. So: A small graftotomy along the blue line. The graft was full of clots from the axilla to the elbow.

The embolectomy catheter was then passed distally along the radial artery and small clots were retrieved. With good back flow. The balloon catheter was then passed along the brachial artery proximally which was clean and some clots were retrieved. The graft and brachial artery were flushed with heparinized saline.

The patient was discharged from the hospital on on regular OPD follow up, he was fine and the new AV access was used without complications.

The patient was referred again to the vascular surgery service with a picture of AV fistula occlusion.

Ultrasound arteriovenous graft evaluation: (12\12\2007) The left AV fistula showed loss of normal color Doppler with evidence of intramural echogenic thrombus starting from its proximal aspect until antecubital region where it joint the brachial artery. Otherwise normal.

Declotting dialysis AV fistula/graft: 30\12\2007. Successful dialysis graft thrombolysis and angioplasty. There was also evidence of central venous stenosis in which it responded to balloon angioplasty.

So What did predispose to all these complications, Were they avoidable ? What shall we do next?