Dialysis Access Intervention Procedure Note (Fistulogram/Angioplasty/Thrombectomy)

Patient: [Patient full name], MRN: [MRN], DOB: [DOB]

Date of Service: [Date of service]

Procedure Start Time: [Start time] End Time: [End time]

Location: [Procedure location]

Primary Operator: [Primary operator name and credentials]

Assistant(s): [Assistant names and credentials] (Omit line if none)

Procedures Performed

• Diagnostic: [Fistulogram / Access circuit venography / Central venography] (List only those performed; omit line if none)
• Therapeutic: [Angioplasty / Thrombectomy / Stent placement / Stent-graft placement / Coil embolization of accessory vein] (List only those performed; omit line if none)
• Guidance: [Ultrasound-guided access / Fluoroscopic guidance / Roadmapping] (List only those performed; omit line if standard technique only)

Indication and Medical Necessity

[Primary indication for intervention: access dysfunction, thrombosed access, elevated venous pressures, prolonged bleeding, arm swelling, etc.] (Do not infer from procedure performed; document only what is explicitly stated)

[Specific clinical findings prompting intervention: cannulation difficulty, inadequate blood flow rates, pressure trends, decreased delivered dialysis dose, abnormal thrill/bruit, edema] [Timeframe of triggering events] (Include only items explicitly mentioned)

Access background: [Access type: AVF / AVG], [Configuration: brachiocephalic / radiocephalic / forearm loop graft / upper arm graft / other], [Laterality], [Relevant prior intervention history] (Include only if explicitly stated)

[Statement of clinical significance linking clinical indicators to imaging-confirmed lesion] (Required for stenosis treatment. If referral documentation unavailable, note this.)

Pre-Procedure Assessment

• History: [Access-related symptoms], [Date/time of last dialysis], [Anticoagulation/antiplatelet status], [Bleeding risk factors], [Infection concerns] (Include only items explicitly mentioned)
• Focused exam: [Thrill/bruit character], [Extremity edema], [Distal perfusion], [Puncture site integrity] (Include only if assessed)
• Labs: [Platelets], [INR], [Other relevant labs] (Include only if available)
• Contrast allergy: [Status and mitigation plan] (Include only if relevant)
• Antibiotic prophylaxis: [Agent], [Dose], [Indication] (Include only if given)

Consent and Safety Verification

Informed consent was obtained from [patient / authorized representative] for the planned intervention(s). Risks discussed included bleeding, vessel injury, access loss, contrast reaction, need for stent, and infection. A procedural time-out was performed confirming correct patient, procedure, site/laterality, allergies, and equipment availability.

Sedation

[Sedation level: minimal / moderate / MAC]. [Medications with doses and routes]. [Sedation start and end times or total duration]. [Monitoring performed]. [Patient tolerance]. (Include this section only if sedation beyond local anesthesia was administered; omit entirely if local anesthesia only)

Technique

[Patient positioning] on the procedure table. The access site was prepped and draped in the usual sterile fashion. Local anesthesia with [Agent] [Total volume] was infiltrated at planned puncture sites. [Heparinization: dose and target ACT if relevant, or rationale for no heparin].

Vascular access to the circuit was obtained via [Puncture site] in a [antegrade / retrograde] approach under [palpation / ultrasound] guidance using a [Sheath size and type]. (If ultrasound guidance used: Ultrasound guidance utilized and images saved per protocol.)

Diagnostic imaging was performed evaluating [Segments evaluated: arterial inflow, anastomosis, juxta-anastomotic segment, access body, outflow vein, cephalic arch, central veins]. (If central veins not evaluated, state reason)

Lesion: [Anatomic location using standard access circuit terminology]

• Lesion morphology: [Focal / Long segment], [Approximate length], [Pre-intervention percent stenosis with reference segment]. (For thrombus: [Location and extent])
• Angioplasty: [Balloon type and size (diameter × length)], [Maximum inflation pressure], [Number of inflations], [Result: residual stenosis percentage, elimination of waist, flow improvement] (Include only if performed)
• Thrombectomy: [Method(s): mechanical device / aspiration / balloon maceration], [Pharmacologic thrombolysis: agent, dose, dwell time], [Result: restoration of outflow] (Include only if performed)
• Stent or stent-graft: [Indication: recoil / rupture / recurrent stenosis], [Device type and size], [Deployment location with landing zones], [Post-dilation details] (Include only if performed)
• Adjunct interventions: [Treatment of rupture/extravasation], [Coil embolization: location and rationale], [Central venous interventions] (Include only if performed)

(Repeat lesion subsection for each additional lesion treated. Include only intervention types that were performed.)

Completion fistulogram/venography demonstrated [Final patency], [Flow quality], [Residual stenosis], [Presence / absence of extravasation], [Clot clearance status].

Hemostasis was achieved with [Sheath removal technique], [Compression method and duration], [Purse-string suture details if placed]. Final access site status: [Status].

Patient tolerated the procedure [well / fairly / poorly]. [Complication details: event, management, and outcome] (Include complication statement only if applicable)

Findings Summary

[Culprit lesion(s) with location and severity]. [Secondary lesions if present]. [Thrombus burden if present]. [Arterial inflow status]. [Central vein status or reason evaluation was limited]. (Provide brief summary for dialysis staff)

Results

• Technical success: [Yes / No]. [Residual stenosis percentage]. [Flow restoration status].
• Access usability: [Patent and adequate for dialysis / Not suitable for dialysis]. [Next steps if not suitable: catheter placement / surgical referral / planned re-intervention] (State only what is explicitly communicated)

Materials and Exposure

Contrast: [Agent] [Total volume in mL] (Note if CO2 used: [CO2 volume])

Medications: [Heparin total dose], [Thrombolytics: agent and dose], [Other relevant medications]

Radiation: [Fluoroscopy time], [Reference air kerma], [Dose-area product] (Include dose metrics if available)

Estimated Blood Loss: [Volume in mL]

Post-Procedure Condition

[Hemostasis status]. [Access site appearance]. [Distal neurovascular status of limb]. [Sedation recovery status if applicable]. Disposition: [Recovery area / Discharge / Return to dialysis unit / Admission].

Dialysis Instructions

• Access use: [May use immediately / Hold cannulation for specified duration] (Include rationale if holding)
• Cannulation guidance: [Permitted segments]. Avoid: [Treated segment / Hematoma / Purse-string site].
• Purse-string care: [Removal timing], [Responsible party for removal] (Include only if purse-string placed)
• Anticoagulation for dialysis: [Standard heparin / Heparin-free dialysis for specified sessions] (Include indication if heparin-free)
• Warning signs requiring urgent evaluation: Recurrent bleeding, loss of thrill, increasing swelling or pain, fever, symptoms of hand ischemia (pain, pallor, coolness, numbness).
• Follow-up plan: [PRN return for recurrent dysfunction / Scheduled recheck / Surgical referral]

Deviations or Limitations

[Procedure aborted/incomplete: what was attempted, why not completed, recommended next step]. [Lesions identified but not treated: location, rationale for deferral, plan]. (Include this section only if procedure was aborted, incomplete, or treatment was deferred; otherwise omit entirely)