This is an (b)(6) year-old gentleman who has had a left upper arm av graft for a few years and was noted to have a defect, possibly in the mid portion of the graft with a "bubble" that was concerning for possible infection and risk of bleeding.He has had a little bit of oozing from the area, but the graft has been used without difficulty and the patient had no evidence of bacteremia or gross infection.The affected area seems to have worsened over time.The patient was advised on multiple occasions to see me for evaluation and possible treatment of this issue, but now that he is hospitalized for mental status changes it was felt that he could be seen and treated as well as needed. description of procedure: the patient was taken to the operating room and given iv ancef for antibiotic prophylaxis.His left arm was prepped and draped in the usual fashion.A tourniquet was present in the room.After a timeout was performed, we injected the skin surrounding the affected area with 1% lidocaine and the patient was sedated.An ellipse was made around the affected area and revealed a hole in the graft.We obtained manual pressure and the patient was given 3000 units of iv heparin.Three minutes later, a sterile tourniquet was applied close to the axilla to stop oozing and bleeding and it was then inflated to 250 mmhg after with the patient's arm was esmarched.No further bleeding was noted and we noted there was a large defect in the graft that could not be salvaged and by definition this is an infected graft, so that portion was excised, but to gain control proximally and distally we needed to find healthy graft to ligate.This was done proximally towards the arterial portion of the graft and distally towards the venous end of the graft where 0 silk ligatures were applied after mobilization of the graft was performed.All wounds were irrigated with ancef and closed in layers including inverted interrupted 3-0 vicryl sutures to approximate subcutaneous tissue, followed by 3-0 nylon mattress sutures for skin closure.Only the portion of the graft affected by the defect was removed.The rest of the graft was ligated.Sterile dressing was applied and an arm brace was applied loosely to prevent the patient from bending his arm.Good distal perfusion was noted.The patient tolerated the procedure well and was transferred to recovery room in stable condition.Blood loss was 50 ml.All counts were correct at the end the case.
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