Thrombectomy  ( Surgery)
Description:  Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia.  Thrombectomy of the left forearm loop graft.  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.

PREOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Local with sedation.,ESTIMATED BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS:, None.,OPERATIVE FINDINGS:,  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.,INDICATIONS: , The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft.  She was not able to have her dialysis as routine.  Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery.  Both Surgery and Anesthesia thought this would be too risky to do.  Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning.  This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.,PROCEDURE: , The patient was taken to the operative suite and prepped and draped in the usual sterile fashion.  A transverse incision was made at the region of the venous anastomosis of the graft.  Further dissection was carried down to the catheter.  The vein appeared to be soft and without thrombus.  This outflow did not appear to be significantly impaired.  A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis.  Next, a thrombectomy was done using a #4 Fogarty catheter.  Some of the clot and thrombus was removed from the venous limb.  The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis.  Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis.  At this point, we felt the patient would benefit from a curettage of the venous limb of the graft.  This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage.  The Fogarty balloon was then passed beyond the clot and the plug.  The plug was visualized and inspected.  This also gave a good brisk bleeding from the graft.  The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb.  Attention was directed up to its anastomosis and the vein.  Fogarty balloon and thrombectomy was also performed well enough into this way.  There was good venous back bleeding following this.  The area was checked for any stenosis with the dilators and none was present.  Next, a #6-0 Prolene suture was used in a running fashion to close the graft.  Just prior to tying the suture, the graft was allowed to flush to move any debris or air.  The suture was also checked at that point for augmentation, which was good.  The suture was tied down and the wound was irrigated with antibiotic solution.  Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges.  Steri-Strips were applied and the patient was taken to recovery in stable condition.  She tolerated the procedure well.  She will be discharged from recovery when stable.  She is to resume her regular dialysis schedule and present for dialysis tomorrow.