History:  End stage renal disease requiring hemodialysis.  Right/Left forearm dialysis graft is clotted.  Last dialysis _____+ days ago.  Last thrombectomy _____.

Procedure:  The venous apex of the dialysis graft was accessed with a micropuncture set and a 6 French vascular sheath was oriented toward the venous outflow.  Over a wire, a Berenstein catheter was advanced to the innominate vein.  Pullback venography showed thrombus at the level of ______.  Mechanical thrombectomy of the venous limb and outflow was performed with multiple passes of the Arrow-Trerotola Percutaneous Thrombolytic Device (PTD).  To access the arterial limb and remove the arterial plug, a second access was needed.  The venous limb of the graft was accessed in the proximal forearm using a micropuncture set and a 6 French sheath was oriented toward the arterial anastomosis.  Mechanical thrombectomy of the arterial limb was performed using multiple passes of the PTD and following restoration of flow, fistulography was performed.

Findings:  The superior vena cava, innominate, subclavian and axillary veins are free of stenosis.  The basilic/brachial/cephalic vein outflow is free of stenosis.

The venous anastomosis is at the level of the medial epicondyle and is free of stenosis.

The graft is free of stenoses.

The arterial anastomosis and forearm arteries are unremarkable.

There is greater than 50% diameter narrowing stenosis of the venous anastomosis.

Intervention:  The venous anastomotic stenosis was treated with “8 x 3” high pressure balloon angioplasty (waist effaced at 20 atm).  Post-angioplasty contrast injection shows an excellent result.

The sheaths were removed and hemostasis was obtained using manual compression.  Upon completion, an excellent trill was felt.  The patient tolerated the procedure well and left the department in good condition.  Dr. _____ was present

Impression:  _____