A study of the arterial inflow was indicated. A Kumpe catheter was advanced retrograde over the 0.035 glidewire into the brachial artery above the anastomosis, and then up to the subclavian. Contrast was injected through the Kumpe catheter, demonstrating an unremarkable subclavian artery, somewhat irregular axillary artery with bridging collaterals, high bifurcation of the brachial artery with the radial equivalent as the feeding artery and no spontaneous flow distal to the anastomosis, the ulnar equivalent feeding the hand with cross antecubital collaterals feeding antegrade and retrograde radial flow below the anastomosis. The anastomosis was found to be widely sizable, and the leading end of the access to be widely patent.

Attention was turned to the aneurysmal leading end. After infiltration with local anesthetic, an elliptical incision was made over the access to the arterial anastomosis. The leading neck was dissected first with sharp and electrosurgical dissection for proximal control, and then the skeletonization of the access was then completed for four inches. The leading end of the access was carefully dissected to the point of previous arterial anastomosis, which proved to be almost two cm long. The artery was carefully dissected above and below the point of previous arterial anastomosis with proximal and distal control achieved with vessiloops. The afferent artery was easily over 12mm in diameter

The anterior wall of the access was gathered in, reducing its circumference, and clamped with a long vascular clamp to reduce it to an acceptable size tapering toward the anastomosis but well short of it. An elliptical anterior portion of the aneurysm was then excised. The incision was closed with a double running 5-0 prolene suture. When the closure was complete, the clamp was removed. The suture line was reinforced at intervals with interrupted prolene sutures.

The arterial end was then doubly clamped and a section of aneurysmal fistula removed from the anastomosis to the leading end of the reduced section, approximately 4 cm. The artery/access anastomosis was carefully taken down and the artery flushed with heparinized saline, then controlled with bulldogs. The previous anastomosis was trimmed to clean edges and repaired with a double running 6-0 prolene, reducing the length of the anastomosis from 2 cm to approximately 7mm.

Sufficient redundant fistula was mobilized to allow an end to side re-anastomosis without undue tension, which was then performed with running 6-0 prolene. When the closure was complete, the clamps were removed, restoring flow. Suture line leakage was addressed with interrupted prolene repair sutures. An excellent thrill was felt in the fistula.

Flow measurements were performed. Repeat flows were in the 2100-2400 cc/min range. Banding of the inflow was indicated to prevent recurrence and to further reduce flows. A 8mm bovine pericardial patch was brought to the field and placed around the access, then closed with interrupted 6-0 prolene sutures, tacking the bottom edge of the band to the suture line. The pericardial patch band was tightened with successive 5-0 prolene sutures and repeated flow measurements untill the flows were consistently in the 1500-1700 cc/min range. A strong and reasonable thrill was still appreciated in the access.

A study of the arterial inflow was repeated. The Kumpe catheter was advanced retrograde over the 0.035 glidewire into the brachial artery above the anastomosis, and then up to the subclavian. Contrast was injected through the Kumpe catheter, demonstrating the same feeding artery with no spontaneous flow distal to the anastomosis, and the ulnar equivalent with cross antecubital collaterals feeding antegrade and retrograde radial flow below the anastomosis. The anastomosis was found to be patent but reduced, and the leading end of the access to be also reduced in size. Two vascular clips were placed on the feeding artery distal to the anastomosis, and the injection repeated. The retrograde flow through the collaterals was largely eliminated, and the flow to the hand visually augmented. Flow measurements were performed. Final flows were in the 1460 cc/min range. N o further intervention being indicated, the Kumpe catheter and sheath was removed, and the site sutured.

Anastomosis and bot6h repairs (arterial and aneurysmoplasty) were examined for bleeding and none being found all Gelfoam was removed. The wound was then made hemostatic with Bovie electrocautery, irrigated with antibiotic saline and closed with interrupted 4-0 prolene vertical mattress sutures over a ¼ inch penrose drain coming out a dependent stab wound. Sterile dressings were applied. Estimated blood loss was minimal. Non-ionic contrast was use due to the patients history of renal failure. The approximate amount used was less than 100 cc. The patient was allowed to leave the operating room having tolerated the procedure well. The operative time expended in this case was almost 4 hours (cut 08:56, close 12:50).

Accompanying codes:
1) Fistulogram of left superficialized brachiocephalic fistula (36901).
2) Selective arterial catheterization from shunt, 2nd order vessel (36216)
3) Arteriogram (75710)
4) Ultrasound guidance for shunt access (76942)
5) Revision with aneurysmoplasty (36832)
6) Segmental resection and repair of fistula (36832-59)
7) Repair of proximal brachial artery (35206)
8) Ligation of distal brachial artery (???)
9) Banding of inflow (37607)