Fistulogram for a Cephalic Arch Aneurysm
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Procedure Outline
Table of Contents
- Identify the arteriovenous fistula anastomosis and assess for areas of stenosis
- Perform proximal and distal scanning to evaluate for aneurysm or pseudoaneurysm formation and thrombus burden
- Infiltrate local anesthetic (e.g., lidocaine) at the planned access site, typically just distal to the anastomosis
- Obtain ultrasound-guided access using a micropuncture needle introduced at approximately a 45-degree angle
- Advance the microwire through the needle and confirm intraluminal position under fluoroscopy
- Remove the micropuncture needle over the wire
- Insert the micropuncture sheath and remove the dilator and wire
- Perform an initial contrast injection through the microsheath to confirm access and visualize access trajectory
- Advance a Bentson wire and exchange the microsheath for a short 6 French sheath
- Use a Kumpe catheter to obtain digital subtraction angiography (DSA) of the aneurysm
- Advance a hydrophilic wire (e.g., V-18 or Hydro ST) to traverse the aneurysm into the central venous system
- Obtain DSA imaging of the brachiocephalic vein and superior vena cava to assess venous outflow and identify any flow-limiting stenosis
- Perform a retrograde DSA by injecting contrast through the sheath while applying compression proximal to the fistula to assess distal outflow
- Remove the catheter and guidewire
- Place a 3-0 nylon purse-string suture around the sheath entry site
- Cinch the suture as the sheath is withdrawn to achieve hemostasis
