Page 11 - Carotid and peripheral vascular interventions textbook
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                                                                     In case of failure from arm approach, a common
                   Table 14-2. Indications for arm/central venography
                                                                 femoral vein is normally used. A 6-Fr 70 cm Flexor
                   To evaluate:                                  Raabe sheath (Cook), DuraSheath (BMV Medical),
                                                                 or Destination  guiding sheath or a 7-Fr 70-80 cm
                   •  Anatomy for preoperative planning of dialysis access surgery
                                                                 Brite-tip sheath (Cordis) is inserted in the common
                     (arteriovenous f stula or graft creation)
                   •  Anatomy prior to central venous catheter (e.g., peripherally   femoral venous access site and positioned near the
                     inserted central catheter [PICC], long-term central venous   ostium of the brachiocephalic vein. For stent diameter
                     catheters, ports) or pacemaker placement    up to 14 mm, 7-Fr diameter sheaths can be employed
                   •  Upper extremity superf cial and/or deep vein thrombosis  to delivered the stents.
                   •  CVD secondary to long-term indwelling catheters, mediastinal
                     f brosis, thoracic malignancy, or radiotherapy  CROSSING THE LESION
                   •  Hemodialysis shunt dysfunction
                   •  Central venous catheter related stenosis/occlusion
                                                                     A 5-Fr or 6-Fr JR4 or MP diagnostic catheter is placed
                                                                 inside a sheath and advanced up to the stenotic lesion
                                                                 or occlusion site of the brachiocephalic or subclavian
                 SHEATH PLACEMENT                                vein. In general, it is preferable to treat the lesion from
                                                                 the hemodialysis access, since it is simpler and a shorter
                     A 20-gauge Jelco  catheter over needle is usually   distance when compared with working from the femoral
                 used to enter the venous outf ow of the AV f stula or    approach, which may necessitate a long introducer sheath
                 graft or superf cial vein (e.g., cephalic or basilic) from   to provide stable access. A 0.035” J-tip or angle-tip
                 the arm. Importantly, sterile technique is used and     hydrophilic Glidewire  (Terumo) is usually the wire of
                 local anesthesia inf ltrated in area of access prior to    choice to cross via the stenotic or occluded vein segment
                 access needle introduction. Once the needle tip is conf rmed   (Fig. 14-7). The “J” shape tip protects from “digging”
                 to be within the lumen with pulsatile backf ow of blood,   into the wall of the vein and potentially perforating out
                 a 0.018” guide wire is introduced and passed through    of the side of the vein. Typical techniques include using
                 the lumen of vein graft. Sometimes, passing a guide   coaxial support catheters and sheaths, back and front ends
                 wire via needle into vein is diff cult which is caused by     of guide wires, and sharp needle techniques.
                 guide wire in side branch, guide wire against stenosis/     If the 5-Fr or 6-Fr catheter is not advanced, it is
                 occlusion or valve. It is recommended to pull back     switched for a 4-Fr hydrophilic catheter (Glidecath ,
                 the wire and redirect under f uoroscopy or advance    Terumo) to cross or needed pre-dilatation with a 0.014”
                 the  Jelco   catheter  over  wire  and  perform AV    or 0.018” small prof le coronary or peripheral balloon.
                 f stulogram and central venogram to def ne anatomy    When the stenotic lesion is traversed with the hydrophilic
                 or pathology. DSA using hand injection with 50:50     guide wire, the catheter is then forwarded over the lesion
                 contrast and saline is then performed. If a patient     and switched for a 0.035” Amplatz super stiff™ wire
                 has central venous obstruction and requires angioplasty   (Boston Scientif c) that offers increased support to passage
                 or stenting, the 20-gauge Jelco  catheter is switched     of a balloon catheter across the lesion.
                 for a 6-Fr radial sheath placed into the graft access.                                              437
                 The  sheath  (together  with  the  dilator  inserted)  is   Wiring techniques for central
                 then introduced over the guide wire to the vein graft.  venous occlusion

                 A small superf cial skin incision can be made where        For occlusions that are unable to be easily crossed,
                 the guide wire enters through the skin to enable smooth   two-way approach should be considered from AV shunt
                 crossing of the sheath. Once the sheath is completely   access and common femoral vein. With an occlusion,
                 advanced, the guide wire and the dilator assembly can     one should closely examine the venogram on both ends
                 be removed. The radial sheath can accept 0.035” guide   for any “nipple” or focal beak-like area (venous stump)
                 wires over which it can be exchanged out for a larger    that can be a starting point to begin probing with the
                 diameter sheath (7-Fr) and longer sheath (25 cm) depending   Glidewire  (Fig. 14-8). Antegrade approach from the
                 on the procedure.                               arm access is sometimes useful to cross to another end
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