#14. BRACHIOULNAR BYPASS GRAFT

PREOPERATIVE DIAGNOSIS: Right upper extremity ischemia; thrombosed right brachio-ulnar saphenous vein bypass graft.

POSTOPERATIVE DIAGNOSIS: Right upper extremity ischemia; thrombosed right brachio-ulnar bypass graft.

PROCEDURE:
1. Selective catheterization right brachial artery via right common femoral artery approach.
2. Selective right upper extremity angiogram.
3. StarClose right femoral artery.

SURGEON: Charles Wyble, MD

ASSISTANT:

ANESTHESIA: Conscious sedation (Versed 2.5 mg intravenous; fentanyl 75 mcg intravenous); 2% lidocaine solution.

ANESTHESIOLOGIST:

ESTIMATED BLOOD LOSS: Minimal.

SPECIMEN REMOVED:

COMPLICATIONS: None.

FINDINGS: Right upper extremity angiogram common femoral, mild irregularity in the mid right subclavian artery. An 8‑inch right axillary and brachial artery in the upper arm. Occluded right brachial artery near elbow. Occluded brachio‑ulnar bypass graft. Reconstitution of the probable interosseous artery in the forearm. Occluded right radial and ulnar arteries. Reconstitution of a possible radial palmar arch vessel.

INDICATIONS FOR THE PROCEDURE: The patient is a 19-year-old white male with a past medical history significant for right upper extremity ischemia experienced after a fall injury requiring right brachio-ulnar reversed greater saphenous vein bypass grafting and thrombectomy. His postoperative course was characterized by bypass graft thrombosis prompting thrombectomy. He was anticoagulated, but represented complaining of right arm pain with associated numbness and discoloration. Arterial duplex demonstrated a patent right brachial artery with an occluded bypass graft.

On physical examination, the right arm is viable, but ischemic. He now requires a right upper extremity angiogram for possible intervention and anatomic definition for possible repeat reconstruction. The risks and benefits were reiterated, not limited to bleeding, infection, artery injuring including thrombosis/dissection/embolism, needs for future reintervention, limb loss, and renal failure. He understands and wishes to proceed with the intervention.

DETAILS OF THE PROCEDURE: The patient was consented for right upper extremity angiography for possible intervention. He stayed in vascular institute and placed in a supine position on the table. After adequate conscious anesthesia was achieved, the right groin was prepped and draped in the usual sterile fashion. A 2% lidocaine solution was used to anesthetize the right groin region.

The right common femoral artery was access percutaneously with an 18-gauze Seldinger needle. A 0.035 Bentson wire was advanced without resistance into the infrarenal abdominal aorta. The needle was removed. A 6-French sheath was positioned within the right femoral artery. The inner dilator guidewire were removed. The sheath was irrigated with heparinized saline solution.

Selective catheterization of the right subclavian, axillary, and brachial arteries was performed using a catheter with a 0.035-angle guidewire. The patient was anticoagulated with heparin.

A selective right upper extremity angiogram was performed using sedations. Imaging revealed a patent right subclavian, axillary or brachial artery. There was mild irregularity in the mid right subclavian artery without evidence of dissection. The right brachial artery was occluded near the elbow. The right radial and ulnar arteries were also occluded. There was reconstitution of the interosseous artery in the forearm region. Images of the hand revealed reconstitution of a possible radial palmar arch segment. No intervention was recommended. Next, lytic therapy was contraindicated secondary to a recent cerebrovascular accident. The procedure was terminated.

The 5-F catheter was removed using the Bentson wire. StarClose of the right femoral common artery was performed. The right femoral sheath was removed and exchanged for the manufactured sheath. Inner dilator and guidewire were removed. The StarClose device was advanced in the port using the 4-step method. Pressure was applied with no hematoma formation. Sterile dressings were placed.

The patient tolerated the procedure well and was transported to the recovery area in stable condition. I was present for the entire procedure including selective catheter placement on the right brachial artery and selective right upper extremity angiography.

cc: Charles Wyble, MD office