PROCEDURES:
1. Ultrasound-guided percutaneous access of L basilic and brachial veins
2. LUE venography
3. L Innominate vein angioplasty
4. LUE venous Intavascular ultrasoun
5. Completion angiography
6. Supervision and interpretation of the above
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine on the operating table, had anesthesia induced with no complications. Under ultrasound guidance the L basilic vein was accessed. This was somewhat difficult because there was obstruction and or scarring of this vein upon entrance. With a micropuncture sheath in place a venogram was performed. This showed a diminutive basilic vein which occludes in the upper arm. The axillary vein did not appear normal as there were multiple collaterals seen in the axilla. As there was no connection between the basilic vein and the axillary vein I decided to puncture high in the arm. I was able to puncture what appeared to be the exillary vein and place a 6F sheath. 3000 units of heparin were given. I was able to navigate with a KMP catheter and angled gluidewire into the subclavian , innominate and R atrium. Angiography of this segment revealed a venous aneurysm off of a colateral to the subclavian vein. No thrombus apparent. The subclavian vein appear patent. The innominate vein appeared patent but with flow changes consistent with possible obstruction.
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We then used ICU to evaluate the central segment. It appeared on IVUS that the innominate was narrow and flattened. No thrombus. We dilated this segment with a 12x40mm PTA. Brisk flow was notice post dilation. We attemted to acces the axillary vein retrograde but this was unsuccessful due to apparent occlusion.
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