Clot Post Operative Report

EXAMS:
003653702 PERC THROM VENOUS INI

1. RIGHT UPPER EXTREMITY VENOGRAM.
2. THROMBOLYSIS/THROMBECTOMY OF THE BRACHIAL, AXILLARY AND SUBCLAVIAN
VEINS.
3. VENOPLASTY OF THE BRACHIAL, AXILLARY AND SUBCLAVIAN VEINS.

EXAM DATE AND TIME: 11/18/2020 17:10

INDICATION/DIAGNOSIS: 40-year-old male with recurrent bilateral upper
extremity deep vein thrombosis presented to the emergency department
with right shoulder pain. Venous duplex ultrasound demonstrated acute
DVT within the right brachial, axillary and subclavian veins.
Catheter directed thrombolysis initiated 11/17/2020.

PHYSICIAN: Cosette Stahl, DO

ASSISTANT: None.

CONTRAST: 80 mL Isovue 250.

SEDATION: Moderate sedation was administered by a trained independent
observer under my direct supervision. The independent observer
provided constant monitoring of the patient and was present, with me,
through the entire procedure. Total sedation time: 160 minutes.

* Versed, 3 mg
* Fentanyl, 300 mcg
* Nitroglycerin, 200 mcg

CONSENT: After the procedure, risks, and benefits were discussed with
the patient, informed consent was obtained.

TECHNIQUE/FINDINGS: The patient was placed supine on the angiography
table. The right arm and existing sheath and catheter were prepped and
draped in usual sterile fashion. The procedure was performed using
maximal sterile barrier technique including cap, mask, sterile gown,
sterile gloves, large sterile sheet, hand hygiene, and 2%
chlorhexidine scrub for cutaneous antisepsis.

The subcutaneous tissue surrounding the sheath were anesthetized with
1% lidocaine. The because infusion catheter was removed over an 035
stiff Glidewire. Digital subtraction angiography was performed through
the sheath. This demonstrated duplication of the brachial and axillary
veins. One of the brachial veins is markedly diminutive in caliber.
There is nonocclusive thrombus extending from the bifurcation of the
brachial vein into the duplicated brachial veins with the majority of
thrombus noted in the more dominant brachial vein. There is near
occlusive thrombus of one of the duplicated axillary veins. A 4 French
Berenstein catheter and 035 Glidewire were advanced through the more
atretic, diminutive brachial vein into the axillary vein. Digital
subtraction angiography was performed, demonstrating near occlusive
thrombus with probable high-grade stenosis of the subclavian vein just
under the clavicle.

A 6 French AngioJet catheter was advanced through the sheath into the
more atretic brachial and axillary veins and into the subclavian vein.
TPA was administered with a pulse spray technique through the
subclavian, axillary and brachial veins. Then, the catheter was
negotiated into the more dominant brachial and axillary veins and then
into the subclavian vein. Again, TPA was administered using PulseSpray
technique. A total of 10 mg of TPA and 50 mL of normal saline were
administered. Clot was allowed to lyse for 5 minutes. Then, the
AngioJet catheter was used to perform thrombectomy. This was performed
through the duplicated brachial and axillary veins, as well as the
subclavian vein.

Follow-up digital subtraction angiography demonstrated near resolution
of thrombus in the brachial veins, with a small focus of nonocclusive
thrombus remaining in the central aspect of the dominant brachial
vein. A Kumpe catheter was negotiated into the axillary vein for
better imaging. Distal subtraction angiography was performed,
demonstrating a persistent thrombus in the subclavian vein, just
peripheral to the focal stenosis.

The dominant axial and brachial veins were angioplastied using a 7 mm
x 60 mm angioplasty balloon. The atretic brachial vein was not
dilated. Balloon maceration of residual thrombus was performed in the
subclavian vein, using 9 mm and 10 mm angioplasty balloons. Digital
subtraction angiography demonstrated some residual thrombus. Again,
thrombectomy was performed using the AngioJet catheter. Once all clot
had been resolved, angioplasty of the subclavian vein was performed.
This was performed using a 9 mm x 40 mm angioplasty balloon and a 10
mm x 40 mm angioplasty balloon. Prolonged inflation was performed
several times with each balloon. Despite angioplasty, there was
persistent apparent narrowing of the subclavian vein, likely related
to elastic recoil. No residual thrombus was noted in the right upper
extremity. The sheath was subsequently removed. Hemostasis was
achieved with manual compression.

FLUOROSCOPY METRICS: Air kerma: 38.4 mGy or Time: N/A and Images:
N/A.

ESTIMATED BLOOD LOSS: Less than 10 mL.

SPECIMENS: None

COMPLICATIONS: None

IMPRESSION:
1. Successful thrombolysis/thrombectomy of the brachial, axillary and
subclavian veins.
2. Apparent high-grade stenosis of the subclavian vein, angioplastied
up to 10 mm. Follow-up digital subtraction venography demonstrated
persistent narrowing of the subclavian vein, despite angioplasty.
Consider consultation with vascular surgery.