Fistulogram for a Cephalic Arch Aneurysm

CHAPTER 1

Hi, my name is Anahita Dua. I'm a vascular surgeon at the the Mass General Hospital and Associate Professor of Surgery at Harvard Medical School. And today we are gonna be taking care of a 63-year-old male who has been on dialysis and currently is coming to see me because he has a large pseudoaneurysm in his cephalic vein. So what we'll be doing today is actually inserting a needle into his fistula, shooting dye into the fistula to evaluate the entirety of it, otherwise known as a fistulogram. And what we'll be looking at is the outflow and the inflow of that fistula. The outflow will be the cephalic vein, and the inflow will be basically the anastomosis between the cephalic vein and the radial artery.

CHAPTER 2

To begin with... You can see obviously that that's the, we do a lot of these in southern New Hampshire, by the way. So you can see, like, that's obviously the vein, right? Right, and you can see some pretty big branches coming off there, okay? But, so it's already dilated up, obviously a beautiful working fistula. Coming down, coming down, coming down, and that is gonna be the connection. Down there, so if we press these, only artery's left, right? You see the artery pulsating? And when I release it, vein's open. That's how you know for sure, right? And then as we go down, it follows all the way down, right? Come up here now again. There's the connection going up. So, I'm gonna just take, Start out by taking a nice look. Okay, that's aneurysmal, but it's not a concern. Like that's very typical. I don't see any thrombus or anything, looks good. I have a bit more of that. A pretty beautiful fistula, I gotta say. Do you have any trouble when you get dialysis with your, does your hand feel numb or anything like that? No. No, you're good, right? And when was this fistula made? Do you remember the month by any chance? It's okay if you don't, just asking. I think it was August of 2021. Yeah, it's gorgeous. It's a really gorgeous fistula. It's about four years ago. Yeah, it's really pretty. In order to do a completion fistulogram, right? There are two important things. Number one, what is going on in the central aspect of things where you basically have the patient hold their breath, take a shot, and ensure that as that vein comes in and deep dives into the SVC, that there's no stenosis. And the second giant thing is, let's say you do all that, a full fistilogram, you have to look at the anastomosis as well. Now, to be fair, this anastomosis looks absolutely gorgeous on ultrasound, but again, at Southern, we do a ton of these, and very frequently it's the inflow that's the issue. And then what you have to do is you press really hard here, really hard, and then you, right, and it retrograde reflux. But let's say there is an issue there, you have to stick it this way. So it's not uncommon, especially in thrombosed fistulas and stuff that you have to go both ways and do stuff, okay? Can you show me the AV fistula right now? Of course, yeah. I thought it was a little bit more proximal to where yeah, that's where though it was. Right, yeah, here. Right here. Where are you - yeah, yeah. Like in this area here. But it's interesting, you see this incision? So it would be probably like right about there. But we know that that's, so we know that that's not the issue. So we don't... The ideal thing is always that you go as close to it as possible without actually being in the area. So, but right here, you know, there's no reason to, like, this is all gorgeous and we know that that's okay. Now, if he had come with an issue like the fistula is not working, one of the things you would say is, wow, look at those huge branches coming off. You know those huge branches, that they might need to be ligated.

CHAPTER 3

Little poke and a burn, this is just the numbing. I lift up because you don't want to, okay. I'll take that please.

CHAPTER 4

So with this one, I don't do an incision. And a lot of times I don't even... Right in, do you see the needle right there? Right, go ahead. You have to be super careful. Tell me if it's going easy. Easy. Easy, easy. Okay, now I'm going to drop, let it take whichever angle you want it to take, and then whichever angle it's in, now that's the way you want to go versus holding it in that particular position. Okay, let's take a look, please. I will say it's quite pulsatile, which by the way, so that's bad because that means that there's something potentially central. However, when you have big aneurysms like that, it can also be pulsatile. And that's just got to do with the way the flow is. A little bit more, so that's clearly quite good. I'll take the microcatheter, please. Thank you. Thank you. How are you doing, my dear, you okay? Yeah. Good, excellent, all right, let's begin.

CHAPTER 5

I'll take some dye, please, 50/50 is fine. Can we come a little bit, yeah, please. We'll just like start here and then we'll go all the way to the chest. I'm gonna pull this back a little bit so that we can really see the whole thing. Right. So that fits very much with what we are seeing on ultrasound. Okay, may I please get the, why don't you give me the Benson, please? And then I'll take that short six. So the fistulogram sheets are much smaller than the shorter. So you have to be very careful. Yeah, oh, of course. Because they can come right out. Coiling in that aneurysm, see that? Okay. Now, may I please have, you're gonna feel a little bit of a push, okay, nothing crazy. That short sticks there, please. And when I press down on it though, like when I do what I'm doing right now, I feel a nice thrill, so I know that the flow is fine. The real question is gonna be that. And what happens in these cases is you can stent it, but right now he doesn't need, that's not what is necessary. Yeah, there we go. Okay, go ahead and put the comfy catheter on here, please. Can I have some heparin saline? Thank you, thank you. Thank you, wonderful, okay. Hold tight, excellent. So why don't we come to about this region and we're gonna take one shot from here and then we're gonna take a central shot with him holding his breath. Take some dye, please. Thank you so much. All right, Alex, if you'll widen up and down, just a touch for me, please. Thank you very much, beautiful. Oh, looks pretty good. That, you see this right at the mid-portion right there, right there, that's what they're talking about, they're concerned about. Yep, so we'll do a few views of that. Is it more just like a venous aneurysm? Because you see there's some stenosis distally. So that's probably poststenotic dilation, so we're probably gonna have to touch that a little bit. And what's happened is because that's so tight. Now, the problem is though, in these patients, so rib resections are indicated for obviously thoracic outlet syndrome, but also in patients that have great fistulas where they're starting to get tightness or problems in that one location and let's say you want to stent it or you want to balloon it, you want to stay open, you're not gonna be able to do that if there's a rib there, of course, just like you can't do it in any other, so occasionally in some patients with very, like, you want to really maintain the dialysis, this is a beautiful fistula, right? So you wouldn't want to lose it. That's not what's going on here, but you can clearly see, and we'll get a little bit closer. Can I have, why don't you give me a glide wire, please? Alex, if you don't mind. Yep, thank you. Is this the long one? Short one. It's okay. I just need to get this in, should be okay, right? Should be all right. Yeah. So we're just going to sneak past that. And Alex, I may need a V18 'cause I might have to... Do you want the short or you want the long one? What's going on here? A little long, please. Actually, you know what, Alex? Why don't you just give me that to begin with? Some action going on here with this comfy. 'Cause then what we'll do is we'll take the V18 and we'll go up to there. We'll shoot the shot because we might have to do that distal because I think things are fine. The problem is if he thrombosis there, everything goes out. And there's definitely poststenotic, like, you can see it, but we'll see it more clearly as we get closer. This is like an opposite poststenotic? Because typically, the dilatation should be afterwards or distal to it, right, but this is right before? Yes, it depends on which way the flow is going. Remember this is the fistula, right? So the flow is different than per usual, okay. Hold on one moment here, all right, lovely. That's the aneurysm there, okay. So we're going to wanna come a little bit closer. We don't want to cause any trouble with it, obviously. All up to here is fine. That's why I picked the V18, 'cause the V18 is really quite, it's going to keep doing that, you know, but let's take this out for a moment and then we'll put a little curve on that in a moment, til then I'll take some dye, please. Sir, I'm going to ask you for a favor, okay? I'm going to ask you, yes sir, yes sir. So, this is what I'm going to ask you to do. In a moment, I'm going to tell you to take a deep breath in, and then I want you to hold your breath, okay? So let's practice, take a deep breath in. Hold your breath, hold it, hold it, hold it, hold it, hold it, hold it, hold it, and you can breathe. Excellent, we're going to do that again, okay? I'll tell you when, deep breath in, hold your breath. Hold it, hold it, hold it, hold it, hold it, hold it, hold it, hold it, hold it, and you can breathe. Excellent. Alex, can you give me a different view of this so I can see, you know, I think this is coming towards us, so I mean, I'm not sure which way, but maybe a little bit of angulation. Yeah, we might have to go up and down. It seems like that's behind the aneurysm, like the aneurysm... I think it's coming up, yeah. So what we want to see is what's the channel in, let's see. Sir, one more time, deep breath in, hold your breath. Hold it, hold it, hold it, hold it, hold it, hold it, hold it, hold it, hold it, and you can breathe. See, the big thing about this is as long as it's not growing, this is an ultrasound-based thing, you'd have to just ultrasound and confirm. It's not going to thrombose, but the real question is, should we do anything, like is there enough stenosis? I mean, stuff is getting stuck in there. Alex, let's do this, let's go very steeply LAO, please. Yep. It's nice, circumscribed, it is absolutely an aneurysm. So the answer to this is a stent. Like, you know, you would put a covered stent across this, but again, look at the location. So, the question then becomes, do you need to do anything? And really the question is, is it growing? Is it, is it, you know... Is it because it's too proximal, or is it...? No, no, no, no, because the ribs there. So if you stented it, you could crush your stent. So unless you started to get into taking the rib out and stuff, you can't just, that's a bad place for a stent. You know what I mean? I'm gonna pull this back a little bit. I wonder if we're like in it a touch. You know, I wonder if we're like in the aneurysm. Could be. Move it more towards you. Will you give 3,000 of heparin, please? 3000. Please. That's great, Alex, thank you. All right, sir, deep breath in, hold your breath. Hold it, hold it, hold it, hold it, hold it, hold it, hold it, hold it, hold it, hold it, hold it. You can breathe. You know, I don't hate... And if you put a covered stent, honestly you could gel that outflow, which could be... Oh, we would. We would 100% gel it because it's gonna be a covered stent. And yes, and that would be, I mean, does it matter is the real question, you know, because you have full, but now that's looking pretty good. Like that doesn't look stenotic to me. You know, it doesn't look like it necessarily needs anything. Alex, can we try all the way the other way and we might have to try cranial. It seems like it's coming towards us. Yeah, maybe let's give that a shot. I don't need him to hold it. That's a little bit better. It is a little bit better. It really does look like it's kind of coming out towards us, you know, a little bit. You want to try the... Let's do it, yeah, please, let's do it. We're almost done, you're doing so well. I almost feel from this view that it's like the whole lump. Like it's not actually got a tail. It's almost like the entirety of it. Do you know what I mean? Like it's like that, versus it's a straight line with a sacular thing coming towards you. In which case... Right. Whereas the CT scan also would fit with, and you see how there's that dilation distally there too. Alex, may I ask you please for a Hydro ST? And then we can go back to just our standard positioning. Thank you so much. You know, he's not having any issues with flow volumes or anything like that. Like none of that's a problem. It's just... Little bit of a 90-degree curve, nothing crazy. See if we can get it, you know, hold that. Ah, we're gonna have to get him to, sir, Yeah. I'm gonna ask you to do that breathing thing for me, okay? Yeah. All right, so take a deep breath in. Hold your breath, hold it, hold it, hold it, hold it, hold it, hold it, hold it. Wonderful, beautiful, great job. So this is all gorgeous. I don't really see any reason to balloon or do anything to this. I think it should just be left alone. It was very easy to flip into it with just the little curve which is indicative of the fact that there's really no stenosis there. Yeah, that V18 that he gave you, may I have that? Can we have a, sorry, a Monocryl on the field, please. So the only way that this would be, I mean, you obviously cannot do it from where we came, right? So the only way that this could really be repaired is to cut down and repair it, alternatively to like basically coil it. The question becomes the utility, like why, you know, so the only reason that you would... Well, that's the thing. So to be fair, it is arterialized. So technically, it's an artery, on the other hand, it's a vein. And, and so if it's not growing and it's not doing anything and there's no thrombus in it and there's nothing, you know, what is the risk of it just rupturing. So, at this point, I don't think that there's anything, but now that I have a good sense of it, the idea basically would be that if we really did need to do something, it would be a covered stent, you know, that would do that, and that would take care of it. Like, we would be done, but I don't know if that's necessary. Well, I mean, that's the thing, you'd have to do that piece, right? So we'd be done, but I don't know if, rib or no rib, I don't think that's the right thing to do. Alex, can you do me one last favor? Can you just measure that for me, please, the aneurysm? The aneurysm? Yes, please, heparin saline, please, to me. All right, my dear, we're gonna be done in two minutes. Okay, you did awesome. We're gonna do that final shot of the retrograde flow. So you're looking at like two-ish, right. You know, that's when you're starting to talk about stuff, right? As long as there's good outflow, because it's perfused and pressurized from it. As long as there's good outflow, there's nothing that should... Make it bigger? Yes. Yes, on the other hand, it's a vein, so it doesn't have the same tensile strength as an artery. So we'll see, and we'll keep an eye on it. It does not need anything currently, Alex, last shot, just of the anastomosis, please. So a little bit lower. Tell me when it's white. It's white. Beautiful, that's the shot you want. I can't look at it and hold it and shoot it. I can't do it, so I have to have somebody else tell me. Butl that's a gorgeous anastomosis, yeah, right? That is a completion fistulogram, that's all the bits. It's interesting, you see that kind of coming off the top? I wonder, you know... Is that a big branch? Clearly, you know, clearly so. Heparin saline, please, and then may I have that Monocryl? So you can go ahead and take the II out. Let me show you this final bit then. So for fistulogram specifically, the way that we close it, and I might need your assistance, thank you.

CHAPTER 6

So what I'd usually do is I will put one stitch like that. You don't want to be too deep, obviously. Almost angle towards that location, right? And then one, kind of like this, pull it over again. Excellent. And then what I'm going to have you do, please. And then just put your finger, yeah, go ahead. You can go ahead and take that out. Just watch the, you see, yeah, just take that, yeah, lovely, good job. Okay, put your finger right there, okay, come down again. Okay, one more time, come out of there, okay. Now let me see what it looks like. That's pretty good. But you just want to maybe put a final, you know, just to be, oh, be careful. Don't hurt yourself, okay, put your finger there. Okay, you have to hold not crazy pressure, okay? You need to be able to feel it or you'll thrombose the fistula. This guy's pretty damn good, but in general, you would. Scissors, please, and if you get a big hematoma, you'll absolutely, you know, cause trouble. A lot of people will use nylon. I use Monocryl because they don't have to have it removed. Come on off there for a moment, I gave 2,000 of heparin, not everybody does that. I usually give a 5,000 of heparin for people. This is really nice, but it might need another stitch, we'll see. You know, you give it like five minutes. You should be super, I mean, it's extremely superficial. So you can imagine an actual bite you would just take, you could occlude the fistula, right? But this is a really nice fistula, I mean, I don't think, he's starting to get some clearly aneurysmal dilation, but I don't think that right this moment anything, and also the other thing that's really beautiful about this fistula is that it's not thrombus laden. Like, you know, sometimes you'll see, and he doesn't have that either. There is a solution to this. It's really a matter of whether or not it's growing. So what I'd like for him is he comes back to see me in a month with an ultrasound of the subclavian vein in its entirety, and measurement specifically of the aneurysm. And we're just gonna follow it, if it's not growing, if it's growing, then we make a move. Let me just see here, that's pretty good. It's pretty good. See that? So just keep your finger there. Maybe give like five minutes or so, just, you know, you want it to not dilate out.

CHAPTER 7

So this is your head, all right? This is your arm. I'm standing over here. When I shot dye into your arm, you see this like lump, this little basketball right there? That's what everyone's freaking out about in you. Because typically, this should just be, you see how this black line is right there like this? This should all just be one black line, but you have this little kind of, you know, pregnancy that's sitting in the middle of your blood vessel, which is fine. As long as it's not growing, as long as it doesn't have clot in it, and as long as it's not disrupting any of your flow. The reason that you were sent to me is there was concern, hey, can this thing burst, you know? Is it possible? It is possible, but in order to repair this the way that it is, if we were gonna put a stent there, we would have to do a pretty, as I mentioned in clinic, extensive surgery where we'd have to take out one of your ribs and it'd be all these theatrics for possibly nothing. So what we're gonna do now that I've seen this and I did a bunch of views and whatnot, and I looked at your entire flow, I know exactly what you look like now compared to your previous fistulograms, and what we're gonna do is follow it along with ultrasound. So no more, no more of these that you just got. And we'll ultrasound it, if this thing grows, right now it's about two by two centimeters in size. If this thing grows, then we'll have a conversation about surgery to repair it. But honestly, I think you're gonna be okay with it being the way that it is currently. And let's pretend that you suddenly noticed, you know, severe pain up here and maybe it did burst, which I don't expect, but let's say that it did. We would come in through your arm just like we did and we would throw a stent right across that region. And obviously that would be an emergency-type thing and then you deal with the other stuff later. But as of right now, this thing has been pretty stable for quite a bit now, you know? What is happening to you, why this is happening, is because your vein, right, and your fistula is really quite excellent. So that vein is getting the pounding of that blood flow, and over time, different sections of it are starting to get bigger and bigger. Okay, you seeing this here? So this is me poking you at your elbow, okay? This is the dye, you can already, so this part right here is this part of your arm, like here-ish, that's not in your chest at all, that's in your arm. And you can already see little lumpy, squiggly stuff here, right? It's the same drama going on in your chest, same vein too. But that is where you're getting poked for your dialysis. So over time, that may also start to act up. It may get to be too thin, it may start to erode, and we'll deal with that when that day comes. But as of right this second, we don't need to do anything more. All right, so we'll get you home. You shouldn't have any pain or anything, you can use your fistula, and I'll see you in a month, we'll make your appointment for the ultrasound to see me. Okay, and let's just do the whole fistula, plus the subclavian vein, specifically independently, so that they don't just look at the fistula, vein and yeah. All right, any questions? All right, great, all done.

CHAPTER 8

Now that you've seen the fistulogram, a couple things to discuss that are important. So this particular patient, as mentioned, has end-stage renal disease and has had a fistula for three years now. Very commonly in patients that have excellent fistulas like this patient has, you will start to see areas of the outflow vein start to dilate up because the vein, of course, is not meant to have arterialized blood in it and arterialized pumping behind it, but unfortunately in the fistula situation, that's exactly what's happening. So certain areas, for example, as you saw in the patient's upper arm, where repeatedly he was being stuck with needles for dialysis, there were areas that were starting to become aneurysmal. Luckily in those areas, we do not see any thrombus, which is excellent. Sometimes in these patients, over time, there's stagnation and swirling within those areas of aneurysmal dilation that can result in thrombus that can ultimately result in occlusion of the fistula. Other issues that can happen are that those aneurysms can get so large that they can actually erode through the skin, which is an emergency and requires you to take the patient to the operating room right away to control bleeding. What you also saw specifically, which is unique to this case, is that there was a large, and I'm going to say large, but it was about two by two centimeter aneurysm within the venous portion of the fistula in the patient's chest. Now, normally when you have something like that, you could potentially just throw a stent across it and you can just close up that area that's a pseudoaneurysm. But in this particular patient, that area that was the pseudoaneurysm unfortunately was right behind one of his ribs, the first rib to be exact, which means that if you put a stent there, you risk potentially that area thrombosing and ultimately losing the entirety of the outflow of that fistula and losing the fistula itself. So if that aneurysm continued to grow and we wanted to stent it, we would have to consider removing the first rib in order to put a stent across it safely. Alternatively, we could do a procedure on this patient where we would actually go in and do an aneurysmorrhaphy, which is a procedure where we cut down on that subclavian vein and we actually take the sides of the aneurysm and we suture them so that we make it basically the same size of the rest of the outflow vein. At this point, it doesn't make any sense to do anything to this particular patient because he has had imaging. He did have a CT scan that was performed approximately a month ago that said that this area was getting smaller. It was already almost one centimeter smaller from what it was previously. So the hope is that given that it's not growing, that it's not going to be a rupture risk, that it's not got any thrombus within it, so it's unlikely that any clot would go anywhere in the patient or would occlude the fistula. So the best thing that we can do at this time is follow up on it, and we will survey this patient with multiple ultrasounds to evaluate that subclavian portion, and probably every six months, a CT scan to ensure that the area is still patent and that the flow is still appropriate.