Morbidity and mortality

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Morbidity and mortality Powered By Docstoc
					Morbidity and mortality


   By:
   Hanaa Tashkandi
   Surgical resident
   KAAU
history
   MRN 865047
   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
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
   PO4 2.11

   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?

				
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posted:2/10/2012
language:English
pages:34