{"id":1800,"date":"2014-05-19T17:40:29","date_gmt":"2014-05-19T22:40:29","guid":{"rendered":"http:\/\/www.medradclinics.com\/?p=1800"},"modified":"2016-04-01T15:13:50","modified_gmt":"2016-04-01T20:13:50","slug":"hemodialysis-access-maintanance-case-4-ken-u-ekechukwu-md-mph-facp","status":"publish","type":"post","link":"https:\/\/www.medradclinics.com\/?p=1800","title":{"rendered":"Hemodialysis Access Maintanance, Case 4. <i> Ken U. Ekechukwu, MD, MPH, FACP. <\/i>"},"content":{"rendered":"\n\t\t<style type=\"text\/css\">\n\t\t\t#gallery-1 {\n\t\t\t\tmargin: auto;\n\t\t\t}\n\t\t\t#gallery-1 .gallery-item {\n\t\t\t\tfloat: left;\n\t\t\t\tmargin-top: 10px;\n\t\t\t\ttext-align: center;\n\t\t\t\twidth: 20%;\n\t\t\t}\n\t\t\t#gallery-1 img {\n\t\t\t\tborder: 2px solid #cfcfcf;\n\t\t\t}\n\t\t\t#gallery-1 .gallery-caption {\n\t\t\t\tmargin-left: 0;\n\t\t\t}\n\t\t\t\/* see gallery_shortcode() in wp-includes\/media.php *\/\n\t\t<\/style>\n\t\t<div id='gallery-1' class='gallery galleryid-1800 gallery-columns-5 gallery-size-thumbnail'><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/www.medradclinics.com\/?attachment_id=1802'><img loading=\"lazy\" decoding=\"async\" width=\"150\" height=\"150\" src=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Before-intervention-150x150.jpg\" class=\"attachment-thumbnail size-thumbnail\" alt=\"\" aria-describedby=\"gallery-1-1802\" srcset=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Before-intervention-150x150.jpg 150w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Before-intervention-109x109.jpg 109w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Before-intervention-100x100.jpg 100w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-1-1802'>\n\t\t\t\tRight brachial venogram before intervention: green arrow is 1st and juxta-anastomotic stenosis; black arrow is proximal aneurysm; red arrow  is 2nd and mid stenosis; brown arrow is 2nd aneurysm; blue arrow is 3rd and distal stenosis.\n\t\t\t\t<\/dd><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/www.medradclinics.com\/?attachment_id=1805'><img loading=\"lazy\" decoding=\"async\" width=\"150\" height=\"150\" src=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Dilating-proximal-and-mid-stenoses-150x150.jpg\" class=\"attachment-thumbnail size-thumbnail\" alt=\"\" aria-describedby=\"gallery-1-1805\" srcset=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Dilating-proximal-and-mid-stenoses-150x150.jpg 150w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Dilating-proximal-and-mid-stenoses-109x109.jpg 109w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Dilating-proximal-and-mid-stenoses-100x100.jpg 100w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-1-1805'>\n\t\t\t\tImage during intervention: angioplasty of 1st and 2nd stenoses.\n\t\t\t\t<\/dd><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/www.medradclinics.com\/?attachment_id=1801'><img loading=\"lazy\" decoding=\"async\" width=\"150\" height=\"150\" src=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/After-dilating-middle-and-distal-stenoses-150x150.jpg\" class=\"attachment-thumbnail size-thumbnail\" alt=\"\" aria-describedby=\"gallery-1-1801\" srcset=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/After-dilating-middle-and-distal-stenoses-150x150.jpg 150w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/After-dilating-middle-and-distal-stenoses-109x109.jpg 109w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/After-dilating-middle-and-distal-stenoses-100x100.jpg 100w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-1-1801'>\n\t\t\t\tRight brachial venogram during intervention: Dilated 2nd and 3rd stenoses; juxtanastomotic stenosis was treated, but image not shown.\n\t\t\t\t<\/dd><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/www.medradclinics.com\/?attachment_id=1803'><img loading=\"lazy\" decoding=\"async\" width=\"150\" height=\"150\" src=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Brachial-artery-150x150.jpg\" class=\"attachment-thumbnail size-thumbnail\" alt=\"\" aria-describedby=\"gallery-1-1803\" srcset=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Brachial-artery-150x150.jpg 150w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Brachial-artery-109x109.jpg 109w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Brachial-artery-100x100.jpg 100w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-1-1803'>\n\t\t\t\tRight brachial arteriogram during intervention: Proximal brachial artery patent.\n\t\t\t\t<\/dd><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/www.medradclinics.com\/?attachment_id=1804'><img loading=\"lazy\" decoding=\"async\" width=\"150\" height=\"150\" src=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Chest-wall-collaterals-due-to-subclavian-stenosis-150x150.jpg\" class=\"attachment-thumbnail size-thumbnail\" alt=\"\" aria-describedby=\"gallery-1-1804\" srcset=\"https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Chest-wall-collaterals-due-to-subclavian-stenosis-150x150.jpg 150w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Chest-wall-collaterals-due-to-subclavian-stenosis-109x109.jpg 109w, https:\/\/www.medradclinics.com\/wp-content\/uploads\/2014\/07\/Chest-wall-collaterals-due-to-subclavian-stenosis-100x100.jpg 100w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-1-1804'>\n\t\t\t\tRight brachial venogram during intervention showing collaterals bypassing subclavian stenosis.\n\t\t\t\t<\/dd><\/dl><br style=\"clear: both\" \/>\n\t\t<\/div>\n\n<p><span style=\"font-size: 22px;\"><strong>Clinical problem<\/strong>: Failed right brachiobrachial fistula.<\/span><\/p>\n<p><span style=\"font-size: 22px;\"><strong>Angiographic findings<\/strong>:<\/span><\/p>\n<ol>\n<li><span style=\"line-height: 1.714285714; font-size: 22px;\">A high-grade juxta-anastomotic venous stenosis.<\/span><\/li>\n<li><span style=\"line-height: 1.714285714; font-size: 22px;\">2 upstream venous aneurysms between which is sandwiched \u00a0a 2nd high-grade venous stenosis.<\/span><\/li>\n<li><span style=\"line-height: 1.714285714; font-size: 22px;\">A 3rd venous stenosis, also high-grade, distal to the distal aneurysm.<\/span><\/li>\n<li><span style=\"line-height: 1.714285714; font-size: 22px;\">Venous collaterals around the right axillary vein due to chronic total occlusion of the right subclavian vein.<\/span><\/li>\n<\/ol>\n<p><span style=\"font-size: 22px;\"><strong>Challenges<\/strong>: Many lesions clustered within a short venous segment with little room for intervention. Accessing the normal downstream brachial vein was difficult because there wasn&#8217;t much room between the patient&#8217;s chest wall and the right arm.<\/span><\/p>\n<p><span style=\"font-size: 22px;\"><strong>Intervention<\/strong>:\u00a0<\/span><\/p>\n<ol>\n<li><span style=\"line-height: 1.714285714; font-size: 22px;\">The proximal right brachial vein was accessed with ultrasound guidance, the needle pointing towards the central veins, and the access secured with a sheath.<\/span><\/li>\n<li><span style=\"line-height: 1.714285714; font-size: 22px;\">A balloon was advanced to the distal venous stenosis and inflated, eliminating the stenosis.<\/span><\/li>\n<li><span style=\"line-height: 1.714285714; font-size: 22px;\">A second access was secured into the downstream brachial vein, pointing towards the right hand, through which the balloon was passed to the juxta-anastomotic and inter-aneurysmal stenoses and inflated.<\/span><\/li>\n<li><span style=\"line-height: 1.714285714; font-size: 22px;\">Reflux angiography of the access circuit was performed and revealed normal arterial limb of the circuit.<\/span><\/li>\n<li><span style=\"line-height: 1.714285714; font-size: 22px;\">Final angiography of the venous limb of the circuit revealed resolved stenoses.<\/span><\/li>\n<li><span style=\"font-size: 22px;\">No action was taken on the aneurysms at this session.<\/span><\/li>\n<li><span style=\"font-size: 22px;\">The subclavian occlusion was not addressed because it did not seem to contribute to the failure of the access.<\/span><\/li>\n<\/ol>\n<p><span style=\"font-size: 22px;\"><strong>\u00a0<\/strong><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Clinical problem: Failed right brachiobrachial fistula. Angiographic findings: A high-grade juxta-anastomotic venous stenosis. 2 upstream venous aneurysms between which is sandwiched \u00a0a 2nd high-grade venous stenosis. A 3rd venous stenosis, also high-grade, distal to the distal aneurysm. Venous collaterals around the right axillary vein due to chronic total occlusion of the right subclavian vein. Challenges: [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[35,89],"tags":[],"class_list":["post-1800","post","type-post","status-publish","format-standard","hentry","category-case-gallery","category-hemodialysis-access-management","pmpro-has-access"],"_links":{"self":[{"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/posts\/1800","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1800"}],"version-history":[{"count":20,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/posts\/1800\/revisions"}],"predecessor-version":[{"id":2557,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/posts\/1800\/revisions\/2557"}],"wp:attachment":[{"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1800"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1800"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1800"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}