Middle Facet Coalition Excision Open Plantar Fasciotomy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left foot middle facet subtalar joint coalition.
2.  Left foot plantar fasciitis.

POSTOPERATIVE DIAGNOSES:
1.  Left foot middle facet subtalar joint coalition.
2.  Left foot plantar fasciitis.

OPERATIONS PERFORMED:
1.  Left foot excision of middle facet coalition with subtalar joint arthroereisis and insertion of GraftJacket spacer.
2.  Left foot open plantar fasciotomy.

SURGEON:  John Doe, DPM

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 20 mL.

PATHOLOGY:  None.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  Under mild IV sedation, the patient was brought back into the operating room and placed on the operating table in a supine position. General anesthesia was then obtained. Thigh tourniquet was then placed on the patient's left thigh. Approximately 10 mL of 1:1 mixture of 2% lidocaine plain and 0.5% Marcaine plain was then injected in an ankle block fashion. The left lower extremity was then scrubbed, prepped and draped in the usual aseptic manner. The lower extremity was then elevated and exsanguinated utilizing an Esmarch bandage. The tourniquet was then inflated. Attention was then directed to the medial aspect of the patient's foot where a lazy-S type of incision was made, traversing along the course of the posterior tibial tendon, starting just proximal to the fibula and extending distal to the area of the navicular tuberosity. The incision was deepened down through superficial and deep structures. Care was taken to identify and retract all vital neural and vascular structures. All bleeders were cauterized and ligated as necessary. Layer by layer, dissection was carried down. The appropriate area of tibial tendon was identified and retracted. Next, the flexor digitorum longus tendon was also identified and retracted. The neurovascular bundle was identified and retracted. The flexor hallucis longus tendon was identified. However, due to its deep nature, it did not need to be mobilized. The individual layers were tagged appropriately for closure at the end of the case. At this time, the dissection was overlying the medial aspect of the sustentaculum tali. Therefore, a periosteal capsular incision was made overlying the sustentaculum tali, starting from distal, extending proximal, overlying the posterior facet. A combination of sharp and blunt dissection was utilized to reflect all soft tissues superiorly and inferiorly off of this bony area. Posterior facet was then exposed. It was followed distally to where the middle facet would be. At this time, a complete bony fusion of the middle facet was noted. There was no joint space appreciated whatsoever. The patient's subtalar joint was put through range of motion and no supination was noted. However, the patient was still able to excessively pronate. The 0.045-inch K-wires were driven from lateral to medial through the sinus tarsi out the area where the middle facet would be, utilizing intraoperative fluoroscopy to confirm proper dissection placement and the presence of this bony coalition. A combination of an osteotome, rotating bur, bone curettes and sagittal saw were utilized to carve out the bony wedge just superior to the true sustentaculum tali and inferior to the body of the talus to re-create the position of the middle facet. Systematically, this bony wedge was carved out to be confluent with the anterior facet and the sinus tarsi as was located by following the posterior facet. Once the bony block was completely excised, the subtalar joint was put through range of motion. At this point, it was noted that there was an additional several degrees of supination and mobilization of the subtalar joint due to the resection of the calcaneal talar middle facet bridge. Intraoperative fluoroscopy confirmed proper bony resection in multiple planes. At this time, the tourniquet was deflated for 10 minutes and then reinflated to allow for reperfusion of the left limb. After the tourniquet was reinflated, an incision was made overlying the lateral aspect of the foot overlying the sinus tarsi. Dissection was carried down into the sinus tarsi where utilizing a guidewire, the HyProCure subtalar joint arthroereisis implant was inserted. Intraoperative fluoroscopy would confirm proper placement up against the talus into the sinus tarsi of this HyProCure device. Once the HyProCure was placed, the excessive pronation was noted to be limited, as the patient was now able to pronate to approximately 4 degrees. The patient still had the additional supination that was created by the resection of the bar. All the areas were then copiously flushed with normal sterile saline. At this time, attention was redirected into the void that was created with resection of the subtalar joint bar. There was bony bleeding noted in that area and a significant void. Decision at this time was made to insert a rolled-up GraftJacket into that area to act as a matrix for fibrous growth and for prevention of bony ingrowth in the area. Also, this was to act as a void filler. The GraftJacket was then rolled up onto itself with the avascular side outward. It was then sewn in place utilizing 4-0 Vicryl. The GraftJacket was then placed inside this area as a filler. Again, the area was copiously flushed with normal sterile saline. Closure was obtained medially in a layered fashion utilizing a combination of 3-0 Vicryl and 4-0 Vicryl. Skin was then reapproximated utilizing 4-0 Prolene in a running locking suture fashion. The lateral incision over the sinus tarsi was closed deep utilizing 4-0 Vicryl and skin was reapproximated utilizing 4-0 Prolene in a horizontal interrupted suture fashion. Next, attention was then directed to the plantar medal aspect of the patient's right heel where the plantar medial tuberosity was palpated. A small stab incision was made overlying this area. Dissection was carried down to free up the plantar fascia both plantarly and superiorly. The plantar fascia was then isolated and incised, utilizing a #15 blade. Excellent release of the plantar fascia was noted upon palpating the arch of the foot. The area was copiously flushed with normal sterile saline and skin was reapproximated utilizing 4-0 Prolene in a simple interrupted suture fashion. All incisional areas were then dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4's, Kling, Kerlix, EBIce cooler, additional cast padding, Ace bandage, posterior splint and additional Ace bandage. The tourniquet was deflated and a prompt hyperemic response was noted to the left lower extremity. The patient was then sent to the recovery room.

Delivery Note - Amniotomy Pitocin Augmentation of Labor Sample

DATE OF DELIVERY:  MM/DD/YYYY

PREDELIVERY DIAGNOSES:
1.  Gravida 1, para 0.
2.  Singleton intrauterine pregnancy at 41 and 2/7 weeks' gestation.
3.  Prolonged rupture of membranes.
4.  Meconium-stained amniotic fluid.
5.  Active labor.

POSTDELIVERY DIAGNOSIS:  Normal spontaneous vaginal delivery of a viable female in the left occipitoanterior position.

ANESTHESIA:  Epidural.

TYPE OF DELIVERY:  Normal spontaneous vaginal delivery of viable female in the LOA position.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  350 mL.

FINDINGS:  Weight 7 pounds 12 ounces. Apgars 8, 9 and 9. Placenta delivered spontaneously intact with 3-vessel cord and meconium noticed. Second-degree perineal laceration repaired with 2-0 chromic under epidural and local anesthesia.

DELIVERY DETAILS:  The patient is a (XX)-year-old female, gravida 1, para 0, at 41 and 2/7 weeks' gestation by LMP, dated by 7-week ultrasound. Her dates are consistent with last menstrual period. The patient presented to Labor and Delivery at 1630 with complaint of spontaneous rupture of membranes at 3 a.m. with regular contractions. Her vaginal exam at 1650 was 3, 100, -2. The patient desired natural childbirth. Due to prolonged rupture of membranes, penicillin prophylaxis was started at 1830. At 0130, she was 6, 100, -1. At 0450, bag was ruptured with meconium-stained amniotic fluid, and she was 8, 100, -1. At 0720, she was 8, 100, 0. At 0950, after epidural anesthesia, she was 10, 100, +1. She progressed to complete, 100 and +1 station at 1150 after resting for 4 hours after epidural anesthesia. Fetal heart tones in the second stage of labor were overall reassuring. She began pushing with direction. She pushed for 1 hour 20 minutes, delivered the head in the LOA position. Bulb suction of mouth and nose at the perineum. Shoulders delivered easily. Progressed to normal spontaneous vaginal delivery of viable female at 1310, delivered onto mom's abdomen. The cord was clamped x2 and cut. Baby was handed to the neonatologist with meconium-stained amniotic fluid. Apgars were 8, 9 and 9. Negative meconium below the cord. The weight was 7 pounds 12 ounces. Placenta delivered spontaneously intact with 3-vessel cord at 1315. Fundus massaged to firm.  Hemostasis achieved easily with an estimated blood loss of 350 mL after Pitocin 30 units IV piggyback given. A second-degree perineal laceration was noted and repaired with 2-0 chromic with local anesthesia. The mother and baby tolerated delivery well.

Upper Arm AV Fistula With Gore-Tex Loop Graft Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  End-stage renal disease secondary to IgA nephropathy, requiring hemodialysis access.

POSTOPERATIVE DIAGNOSIS:  End-stage renal disease secondary to IgA nephropathy, requiring hemodialysis access.

OPERATION PERFORMED:  Right upper arm arteriovenous fistula with a Gore-Tex loop graft.

SURGEON:  John Doe, MD 

ANESTHESIA:  General anesthesia via LMA along with 0.5% Marcaine with epinephrine for local anesthetic.

SPECIMENS:  None.

ESTIMATED BLOOD LOSS:  15 mL.

INDICATIONS FOR OPERATION:  This is a (XX)-year-old male with multiple medical problems and end-stage renal disease secondary to IgA nephropathy. He has been having dialysis via a right internal jugular vein PermCath and has had a left AV fistula created in the past; however, due to occlusion of his central vein on the left side, the AV fistula failed in the long term. Subsequently, the patient has been receiving all hemodialysis through this right internal jugular PermCath for approximately 2 years; however, he has been readmitted to the hospital with gram-negative rod bacteremia. This bacteremia was thought to be secondary to his indwelling dialysis catheter; therefore, this was removed. Therefore, the patient and his wife elected to have a right upper arm AV fistula created using a Gore-Tex graft.

DESCRIPTION OF OPERATION:  The patient was brought to the operating suite and placed in the supine position. General anesthesia was then induced via LMA mask. Preoperative antibiotics consisting of 1 g of Ancef was administered prior to the first skin incision. The patient's right arm was then prepped and draped in normal sterile manner. An approximately 6.5 cm incision was made on the medial aspect of his right upper arm. This incision was then dissected down through the fascia using electrocautery. Once the fascia was opened using sharp dissection with Metzenbaum scissors, the right brachial artery and brachial vein were isolated. Once these 2 vessels were isolated, 2 small approximately 1 cm incisions were made on the medial and lateral aspects of his distal upper arm, and using a 26-French tunneling device, 5 to 7 mm Gore-Tex graft was then placed in a looped manner in the subcutaneous tissue. Starting with the brachial vein, the Gore-Tex graft was anastomosed using a running 6-0 Prolene suture. The brachial artery-to-graft anastomosis was also fashioned using a running 6-0 Prolene suture. The arterial arm of the graft is on the lateral aspect of his upper arm and the venous aspect is on the medial aspect of this arm. Once the arterial and venous limbs were anastomosed, the vascular clamps were removed revealing adequate back flow to the arterial limbs. Using an intraoperative Doppler, there was audible blood flow through the arterial as well as venous limbs. There was a faint palpable thrill in the upper extremity. The two 1 cm incisions in his distal upper arm were then closed in 2 layers using 4-0 Monocryl sutures. The brachial wound was then closed in 2 layers using interrupted 4-0 Monocryl for the deep dermis and running 4-0 subcuticular Monocryl for the skin. The wounds were then dressed in a normal manner with Dermabond and a loose Ace wrap. The patient was awakened from general anesthesia and brought to the recovery room in stable condition. Needle and sponge counts were correct x2. There were no complications. Estimated blood loss was 15 mL. There were no specimens removed.

Laparotomy Small Bowel Resection Jejunostomy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Small bowel anastomotic leak.

POSTOPERATIVE DIAGNOSIS:  Small bowel anastomotic leak.

OPERATIONS PERFORMED:  Exploratory laparotomy; small bowel resection, approximately 1.5 feet; jejunostomy; mucous fistula; placement of an abdominal wound VAC.

SURGEON:  John Doe, MD 

ANESTHESIA:  General endotracheal anesthesia.

SPECIMENS:  Small bowel, approximately 1.5 feet.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  250 mL.

DESCRIPTION OF OPERATION:  The patient was brought to the operating suite and placed in the supine position. General anesthesia was induced. The previously placed wound VAC and Wittmann Patch were then removed without complications. The omentum was adhesed to the anterior small bowel and this was taken down with blunt finger dissection. The small bowel anastomosis was located in the right lower quadrant of her abdominal wound, and upon examination, there was evidence of a 0.5 cm defect at the staple line, which was leaking succus into the abdominal cavity. The loops of small bowel were then traced back. The proximal portion of the anastomosis was traced back to the ligament of Treitz. The estimated distance was approximately 65 cm. The distal portion of the anastomosis was only able to be mobilized approximately 20 cm. Upon distal mobilization of the small bowel, we were able to examine the uterus, which appeared normal, as well as what appeared to be the right fallopian tube. The sigmoid colon and descending colon appeared to be normal without any gross defects. It was decided that the safest procedure to perform was to bring out a proximal jejunostomy and a distal jejunostomy/mucous fistula. The proximal portion of the small bowel was transected using a blue load 55 mm handheld GIA stapler after creating a small opening in the mesentery. The mesentery was mobilized using a handheld LigaSure device, and after making an approximately 4 cm circular opening in her anterior abdominal wall and in her left lower quadrant, the loop of proximal jejunum was brought out through this opening. The small bowel was suture tacked to the anterior abdominal wall with a 3-0 Vicryl suture. The distal jejunum was then also transected using a single 55 mm blue load GIA handheld stapler and the mesentery of this portion of small bowel was also mobilized using a handheld LigaSure device. A second 4 cm circular opening was made in her anterior abdominal wall, in the right lower quadrant, and the distal jejunum was brought out through this opening as well. The small bowel was once again tacked to the anterior abdominal wall using a single 3-0 Vicryl suture. The anastomosis was then completely transected and sent to pathology for further evaluation. The total length of small bowel removed was approximately 1.5 feet. The abdominal cavity was then irrigated using warm normal saline. Hemostasis was achieved using a combination of electrocautery as well as suture ligatures. The proximal jejunostomy and distal jejunostomy were then matured in a normal fashion using interrupted 3-0 Vicryl sutures. The abdominal wound was then covered with an abdominal wound VAC and this was placed to suction. Ostomy bags were then placed over the 2 newly created stomas in the normal fashion. The patient was then brought out of general anesthesia and transferred back to the surgical intensive care unit in critical condition. Estimated blood loss for the procedure was 250 mL. There were no complications. The specimen removed was a total of approximately 1.5 feet of small bowel, which was sent to pathology for further evaluation. Needle and sponge counts were correct x2.

Normal Physical Exam Template Transcription Examples / Samples

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 126/76, pulse 66, weight 180, O2 saturation 99% on room air.
GENERAL:  The patient is alert, oriented, pleasant and friendly. Does not seem anxious or depressed. In no acute physical distress.
HEENT:  NCAT. Pupils are equal, round and reactive. EOMs are intact. No temporal bruits. TMs are gray, nonbulging. No TMJ crepitus. Oropharynx is benign. Dentition intact.
NECK:  Supple without lymphadenopathy or thyromegaly. C-spine range of motion intact. Mild tenderness over the cervical muscles and trapezia bilaterally.
CHEST:  Lung sounds are clear to auscultation. Normal respiratory effort. No rales, wheezes or rhonchi.
CARDIOVASCULAR:  Regular rate and rhythm. S1, S2. No S3, S4 or murmur.
ABDOMEN:  Soft and nontender without guarding, rebound, masses or rigidity. Bowel sounds are normoactive.
GENITOURINARY:  Normal external genitalia. No masses palpated. No hernias.
MUSCULOSKELETAL:  Normal bulk and tone. Gait:  Steady and even. Range of motion of the upper and lower extremities intact and symmetric. Range of motion of the shoulders and neck intact with mild tenderness over the cervical muscles and trapezia as noted above.
NEUROLOGICAL:  No focal deficits. DTRs equal and symmetric. Cranial nerves intact.
SKIN:  Warm and dry. No rashes or suspicious lesions.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a healthy-appearing, somewhat overweight male, in no acute distress.
VITAL SIGNS:  Blood pressure 124/68 in the right arm, in a sitting position, with heart rate of 66, equal in both radial pulses; respiratory rate of 16. Height 64 inches and weight 180 pounds.
SKIN:  Normal. There are no abnormal pigmented lesions, signs of basal or squamous cell carcinomas. No rashes.
HEENT:  Atraumatic, normocephalic. Tympanic membranes are normal. Weber is midline. Conjunctivae and sclerae are clear. Extraocular movements are full. Pupils are equal, 3/3, round and reactive to light. Funduscopic exam is normal. Nasal and oral mucosa normal. Pharynx is negative.
NECK:  Supple. There is no lymphadenopathy. No masses are noted. Carotids are 2/2 without bruits. Trachea is midline. Thyroid is normal.
LUNGS:  Clear to percussion and auscultation.
Pulses in the radial, brachial, carotid, femoral, dorsalis pedis are 2/2 without bruits. There is no adenopathy in the epitrochlear, cervical, supraclavicular, infraclavicular, axillary or inguinal areas.
BREASTS:  Without masses, dimpling, discharge or erythema.
CARDIOVASCULAR:  Without murmurs or gallops.
ABDOMEN:  Normal bowel sounds. No organomegaly. No masses. No tenderness.
GENITOURINARY:  The patient is an uncircumcised male. Testes are descended. No masses are noted.
RECTAL:  Exam is normal. Prostate is not enlarged.
NEUROLOGICAL:  Alert and oriented. Cranial nerves II through XII are intact. Motor and sensory exams are normal. Motor and sensory reflexes are 2+ and symmetric with bilateral plantar responses.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 124/88. Pulse 94 and regular. Height self-reported as 6 feet. Weight 180 pounds.
GENERAL APPEARANCE:  The patient is a pleasant gentleman, in no acute distress.
HEENT:  Normocephalic, atraumatic. Pupils equally round and reactive to light. Oropharynx clear. Tympanic membranes normal bilaterally. Does have a small amount of cerumen in the right external auditory canal.
NECK:  No lymphadenopathy, no thyromegaly, no carotid bruits. Does have some limitation with lateral rotation and there is crepitus with flexion and extension of the neck.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Irregularly irregular with no murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended, with normal bowel sounds. No organomegaly, no masses.
RECTAL:  Mildly enlarged prostate, symmetric, firm and without evidence of mass or nodule.
EXTREMITIES:  No clubbing, cyanosis or edema, +2 patellar reflexes bilaterally. Examination of the left shoulder reveals positive Hawkins and Neer impingement signs. Does also have some mild posterior shoulder joint tenderness. No swelling. Appears to have intact supraspinatus strength but testing is very limited. Does have mildly impaired internal rotation of the shoulder. The right shoulder has a positive Neer impingement sign, but negative Hawkins impingement sign and has a fairly good range of motion at that shoulder with no joint tenderness or swelling.

PHYSICAL EXAMINATION:  Today, blood pressure was 114/74. Pulse was 82. Respiratory rate was 18. A pleasant woman in no acute distress. Neck was supple, no bruits. Negative Lhermitte sign. Cardiovascular:  Regular rhythm. She does have a mild left sternal border murmur. Extremities:  No edema was noted. Neurological:  She was alert. She was oriented x3. She was able to register 3 words immediately and was able to recall 1 out of 3 after 3 minutes. She was able to name the months of the year forwards and backwards without any difficulty. Her speech was somewhat hesitant, however, no paraphasic errors. She was able to copy an abstract figure and was able to draw a clock and place the hands correctly at 10 past 11. On cranial nerve examination, her pupils were about 3 mm, both reactive to light. I did not see any afferent defect. Her right disk was normal; her left disk, was not able to see the presence of a cataract. Her extraocular movements were intact with no nystagmus. Facial sensation and strength were normal. Normal hearing bilaterally. Palate and uvula elevate well and symmetrical. Normal shoulder shrug. Tongue was midline. Motor strength was 5/5 throughout, except for finger extensors that were 4/5 on the right, 5-/ 5 on the left; interossei 4/5 on the right, 5-/ 5 on the left. She had a right pronator drift. Motor strength in her lower extremity was overall quite good. However, she has some decreased velocity of movement on finger tapping and foot tapping bilaterally, right worse than left. She has mild spasticity on her right arm and leg, has postural tremors in both hands. Presence of mild dysmetria on finger-to-nose and heel-to-shin bilaterally. She had decreased pinprick in her right arm and leg. Decreased vibration in toes. Some decreased position sense on her right toe, normal on the left. Her deep tendon reflexes were +3 in the upper extremities, but left was worse than right; +1 in the lower extremities with bilateral upgoing toes. I did not notice any clonus. Her gait was wide-based, a little bit spastic on the right. She was not able to do tandem gait and had a positive Romberg.

Infuse-a-Port Placement With Fluoroscopy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Metastatic melanoma.

POSTOPERATIVE DIAGNOSIS:  Metastatic melanoma.

PROCEDURE PERFORMED:  Placement of Infuse-a-Port with fluoroscopy.

SURGEON:  John Doe, MD

ANESTHESIA:  MAC with local.

ESTIMATED BLOOD LOSS:  Minimal.

DRAINS:  None.

DESCRIPTION OF PROCEDURE:  The patient was brought in to the operating room and placed supine on the operating table and IV sedation was provided.  Area of the neck and chest were prepped and draped in the standard surgical fashion.  Using 1% lidocaine with epinephrine and 0.25% Marcaine with epinephrine, 50:50 mixture, the left clavicle was anesthetized and the anterior chest was anesthetized.

Using a 16-gauge needle, the left subclavian vein was cannulized so that the wire would not spread down to the superior vena cava.  After several manipulations, the procedure was aborted and the procedure was then turned to the right IJ. The right IJ area was anesthetized with the same local.  The needle was then introduced into the right internal jugular vein.  The wire was then passed down to the superior vena cava without difficulty under direct fluoroscopy.  Following that, the area of the right chest was anesthetized.

A small incision was made approximately 2 inches to the left with the scalpel and further carried down with electrocautery.  A pocket was made over the left chest with a blunt dissection.  Port was placed into the pocket.  The dilator and sheath were then placed over the wire using fluoroscopy into the superior vena cava.  Next, the catheter was then tunneled from the chest site to the puncture site with the use of a tunneling device and the kit.  The catheter was then cut to size with the use of fluoroscopy.  The wire and dilator were then removed leaving the sheath intact.  The catheter was then thread down the sheath.  The sheath was then removed.  With fluoroscopy, the catheter was then checked.  It was noted to be in the superior vena cava just above the right atrium.  There seemed to be good adequate blood, which rolled from the port and flushed easily.  The port was then sutured in place with 0 Vicryl to the fascia in the anterior chest wall.

 The subcutaneous tissue of the pocket was then approximated with 3-0 Vicryl interrupted.  The skin was approximated with 4-0 Monocryl running subcuticular.  The puncture site was closed with a single stitch of 4-0 Monocryl in an interrupted fashion.  The area of the chest and neck was cleaned and dried.  Benzoin was applied to the incision site and Steri-Strips were applied.  The port was then flushed with heparin 1000 units per mL, 2 mL used.  The patient was sent to the recovery room in alert, awake and stable condition.  All sponge and instrument counts were correct at the end of the case.  A stat chest x-ray was ordered in the recovery room.

Arm Fistulogram and Cephalic Vein Balloon Angioplasty Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left arteriovenous fistula complication.

POSTOPERATIVE DIAGNOSIS:  Left arteriovenous fistula complication.

PROCEDURE PERFORMED:
1.  Diagnostic left arm fistulogram.
2.  Left arm fistula/cephalic vein balloon angioplasty. 

SURGEON:  John Doe, MD

ANESTHESIA:  General MAC and local.

ESTIMATED BLOOD LOSS:  Negligible.

COMPLICATIONS:  None.

CONTRAST:  Visipaque 10 mL.

INDICATION FOR PROCEDURE:  The patient is a (XX)-year-old male with end-stage renal disease, on hemodialysis. The patient had a left Cimino AV fistula performed in the past with several balloon angioplasties. He developed recurrent stenosis and difficulties with dialysis flow and was recommended the above procedure, which he was agreeable to. The patient was therefore admitted for elective surgery.

PROCEDURE FINDINGS:  Left arm fistulogram showed a mildly severe stenosis, approximately 70-80%, near the arterial anastomosis. Remaining fistula widely patent. No stenosis.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room, where he was given general MAC anesthesia, which he tolerated well. Approximately 3 mL of 1% plain Xylocaine was locally infiltrated per Anesthesia. The left arm fistula was percutaneously accessed in retrograde fashion in the upper forearm guiding the guidewire towards the arterial anastomosis at the wrist. Micropuncture set was used.

A 5-French sheath was inserted. The patient was given 3000 units of IV heparin. Tourniquet was applied to the left upper arm and diagnostic left arm fistulogram performed. This revealed the above-noted findings. Given the stenosis, decision made to treat with balloon angioplasty. Bentson guidewire was used to cross the stenosis. Balloon angioplasty performed with a 6 mm diameter x 4 cm balloon. A severe waist was present, which completely effaced with angioplasty up to 6 atmospheres. Angioplasty was done up to 8 atmospheres for 2 minutes twice. Repeat fistulogram showed an excellent result with complete resolution of the stenosis. The tourniquet was released upon completion of fistulogram performed to the upper arm with no significant other problems. The vein was well dilated throughout the remaining length.

Wires and catheters were removed and the sheath was flushed with heparinized saline solution and then removed. Puncture site closed with a 5-0 Prolene stitch. Sterile dressing was placed. The patient tolerated the procedure well without complication and was taken to the recovery room in stable condition. Needle and sponge counts were correct at the end of the procedure.

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