Description of Event or Problem · 1
OLDER MALE WITH END-STAGE RENAL DISEASE, AND HE RECEIVES DIALYSIS THREE TIMES PER WEEK. HE HAS AN A-V FISTULA FOR DIALYSIS ACCESS IN HIS RIGHT ARM. HIS ARM BECAME SWOLLEN DUE TO RECURRENT CENTRAL STENOSIS, AND HE HAD AN OUTPATIENT VENOUS ANGIOPLASTY TO RETURN HIS FISTULA TO FULL FUNCTIONALITY. HE HAD THE PROCEDURE DONE SEVERAL TIMES BEFORE. DURING THE PROCEDURE, IN WHICH HIS FISTULA WAS ACCESSED WITH AN EVERCROSS 12 MM PTA DILATION CATHETER, THE CATHETER FRAGMENTED AND THE BALLOON BROKE. THE CATHETER FRAGMENT WAS ABLE TO BE FULLY RETRIEVED IN ONE PIECE, BUT THE BALLOON FRAGMENT WAS NOT. WHAT APPEARED TO BE THE BALLOON FRAGMENT WAS SEEN IN THE RIGHT PULMONARY ARTERY. INJECTION OF CONTRAST REVEALED THERE TO BE NO SIGNIFICANT FLOW RATE LIMITATION CAUSED BY THE FRAGMENT. ADDITIONAL UNSUCCESSFUL ATTEMPTS WERE MADE TO RETRIEVE THE BALLOON FRAGMENT. A DECISION WAS MADE NOT TO PURSUE FURTHER ATTEMPTS BASED UPON THE PATIENT'S CLINICAL CONDITION. HE WAS IN NO DISTRESS WITH OXYGEN SATURATION OF 100%. HE WAS OBSERVED OVERNIGHT IN THE HOSPITAL, AND HE CONTINUED TO FEEL WELL WITH NO ADVERSE SEQUELAE. HE WILL CONTINUE TO BE ASSESSED BY HIS NEPHROLOGIST AND PRIMARY CARE PHYSICIAN THREE TIMES PER WEEK. THIS WAS REPORTED TO THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH AS A RETAINED FOREIGN OBJECT.