Ax-ax venous bypass

This is a case of ESRD patient on long term dialysis . Central vein
occlusion was noted. This a axillary to axillary venous bypass with
ePTFE graft was don relieve his limb swelling

Infected dialysis graft- local excision with bypass

This is how we deal with a recurrent dialysis ePTFE infection. The infection is localized at the bending area of the forearm loop graft. The graft was patent with good flow. However, there was repeated graft infection despite of debridement procedures.

Usually we have to deal with this kind of situation aggressively. That is to say, we have to remove all the infected segment of ePTFE graft. In this case, the infected segment (which was located just at the bending portion of the loop) had to be removed. According to the principle of surgery, we did the bypass surgery prior to the removal of infected portion to maintain the flow. We did bypass from the arterial limb to the venous limb, and we have tunneled the new graft through the healthy area to avoid contamination. After the flow of dialysis access was established, we then extracted the infected segment through the previously infected open wound (where the exposed graft lied). The dirty wound had been put on wet dressing.

And the patient can be put on dialysis via the original access without problem since the puncture area was non-touched.

less invasive revascularization

This is a case I have completed today.
A 80 y.o. gentleman ,who suffered from intermittent claudication for a long time. A total occlusion over his left thigh artery was diagnosed. From the angiography above, you can see there is a block on the artery which makes the distal artery lack of blood flow. Since the smptoms getting worse day by day, he was suggested to have a "revascularization".
In the old days, we surgeons tend to do "open bypass" which means insertion of a artifical tube into the leg to drain the blood from healthy arteries to distal artery. Usually the bypass surgery needs to cut multiple wounds on the leg and to make tunnels in the leg to insert the artifical artery. Sure the procedure is a painfula and lengthy procedure with relatively painful recovery course.
Nowadays we adopt the so call "endovascular revascularization". Like in this case, we have just stick a tiny hole on the thigh (without even using a blade!) and insert some king of balloon catheter into the artery. We have found the blockage under X ray and open the blockage by balloon. No cutting or sutures on the artery needed. No painful tunneling in the flesh needed. The recovery course will be very easy to the patient and he will be able to walk a couple of hours later.

Thanks to the endovascualr technique, we can render more effective treatments to patients with artery diseases in a less invasive fashion.

the minimal invasive surgery on aorta disease

In the past , surgery on aorta disease remains to be one of the major procedures in the realm of vascular surgery . The mortality and morbidity remains to be the major concern of those patients suffered from the disease. Thanks to the advance of the medical technology, nowadays we are able to treat lots of aorta dissease in a less invasive fashion. The invention of arotic stentgrafting (endovascualr treatment; EVAR or TEVAR) makes the procedure more safe and less painful for the patients.
Finally, the stentgraft are available in Taiwan sinced 2005. And in our hospital, we vascular surgeons soon adopted the new technique to treat our patients. We can now treat a giant thoracic aneurysm or abdominal aneurysm through tiny holes in the patients groin area!
more information about our institution for those who live abroad: internatinal service center of CGMH

Tip on creating dialysis graft venous anastomosis

A tip about doing the venous anastomosis of a dialysis graft.

When doing the dialysis graft creation, venous anastomosis is one of the important parts of the procedure. A smooth and wide open venous anastomosis is the important to the long term patency of the graft.
Usually, the target vein would became smaller than its original size because of vessel spasm due to the extensive dissection of surrounding tissue and manipulation of the vessel. Small target vessel lumen would add difficulties to the anastomosis. Here is a technique which can made the anastomosis easier.

I usually use a 19 gauge intravenous injection catheter as a simple tool to dilate the target vessel. The IC catheter is inserted into the lumen of the target vein after proximal and distal clamping of the vein. From the IC catheter, normal saline is gently injected. The target vein is thus dilated to a bigger size under the pressure. Then, from the tiny injection hole, I can make a longitudinal incision for following anastomosis.
The graft end will be sutured easily to the dilated target vein. Thus a wider anastomosis can be created.

Treatment of dialysis graft outlet stricture: patch angioplasty

Dialysis graft outelt stricture is one of the most frequent complication/situation that a dialysis surgeon faces in his dailiy practice. To cope with the stenotic lesion, the oldest way, probably the most reliable, is to do surgical revision.
There are two ways of surgical revision of the graft outlet. Here shows the so called" patch angioplasty" method. If the stenotic lesion is a focal or short lesion, we can just longitudinally incise teh graft outlet, and apply a ePTFE patch (which is the same material of the graft) to augment the outelt space. after the operation, the graft outlet should be widely open.
The operation usually takes around 1 hour to perform. ofcourse, reoperation sometimes will be troublesome. However, most of the stenotic lesion can be fixed by patch angioplasty. Only if the lesion is too long, then we will try to fix the lesion using a jump graft.

Ofcourse nowadays most of the graft outelt stenotic lesion are first treated with angioplasty balloons/ stenting, which is less invasive. However, surgeon should always keep himself familiar with the open procedure. and once the PTA doesnt work, we still can provide a feasible choice of treatment instead of giving up the graft!

difficult dialysis access creation- chest loop

This is a dialysis patient with exhausted bilateral arm's venous property. Due to the need of long term dialysis, I have created a anterior chest loop graft for her some 6 years ago. And fortunately, the anterior chest dialysis graft lasted functional for over 6 years. Several weeks ago, because of the degenration of the graft, low flow with frequent thrombosis was noted.
My stratagy is : insert a cuffed tunneled catheter via the right internal jugular vein for dialysis and perform a anterior chest dialysis graft redo procedure. I have implanted a new graft and do the anastomosis of either end of the graft to the original graft inlet and outelt stumps.

I think, with meticulous work and proper clinical judgment, we still can perform dialysis graft for long term usage on those patients whose bilateral arm are not suitable for graft creation. The anterior chest loop graft is one of the form which can/should be considered.