This case illustrates a low-flow situation of a Cimino fistula on the left forearm with a juxta-anastomotic stenosis. Transit Time Flow Measurement (TTFM) and High-frequency Ultrasound Imaging (HFUS) served as completion control.
AV Access reoperation due to low flow
Intraoperative completion control with TTFM and HFUS
Intraoperative imaging showed that the radial artery was calcified and it was decided to proximalize the anastomosis to preserve enough fistula length. In addition, a significant side branch was ligated. Video 1 below shows the transverse view of the juxta-anastomotic stenotic segment of the fistula vein.
Video 1
The initial flow in the stenotic segment of the fistula vein was measured using a 4 mm TTFM probe (Image 2 and Image 3) showing only 122 mL/min with a PI of 0.8.
Completion control post revision
Completion control with TTFM ensured a significant flow increase. The final flow measurement at the fistula vein using a 7 mm TTFM probe (Image 4 and Image 5) confirmed adequate flow of 304 mL/min with a PI of 0.8.
Completion control with HFUS of the fistula vein after proximalization of the AV anastomosis shows an open lumen (Video 6).
Video 7 below shows the whole procedure in more detail.
Video 7
Case attachments
Click images below to view.
TTFM at stenotic segment
TTFM probe placement at stenotic segment
Final TTFM after revision
TTFM probe placement after revision
HFUS post revision
Reference
Case example by Dr. Alexander Meyer, Department of General and Vascular Surgery, Johanniter Krankenhaus Reinhausen, Germany
Technology used
Medistim MiraQ™ Vascular System with TTFM Probes and L15 High-Frequency Ultrasound Probe.
