PMC6319522_01
a Retrograde percutaneous access was obtained through the venous outflow limb of the brachiocephalic AVF and a 6-French sheath was placed. b A guidewire is negotiated across the anastomosis retrogradely into the inflow brachial artery and the juxta-anastomotic venous outflow limb diameter is measured at 13 mm (arrow). c Following this, a 5 x 40 mm angioplasty balloon was inflated to nominal pressure and (d) blunt dissection was performed carefully on either side of the venous outflow limb. e-h The venous outflow limb was stenosed to the profile of the inflated balloon using a constraining 2-0 suture. i Completion fistulogram showing stenosis in the outflow vein (black arrow) and improvement in perfusion of the brachial artery distal to the anastomosis (white arrow) as well as to the hand
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PMC6319522_01_42155_2018_35_Fig1_HTML.jpg
Fig1
A diagnostic fistulogram showed very rapid flow across the AVF with an aneurysmal outflow limb but no distal outflow or central venous stenosis (Fig. 1a). The juxtaanastomotic venous limb measured 13 mm in maximum diameter (Fig. 1b). Terumo, Somerset, NJ) combination. Following this, a 5 x 40 mm angioplasty balloon (EverCross; Covidien, Plymouth, MN) was placed across the venous outflow limb in the juxta-anastomotic region and inflated to nominal pressure using a mechanical inflation device (Fig. 1c). Two small incisions were made on either side of the inflated balloon and blunt dissection was carefully performed superficial and deep to the outflow vein (Fig. 1d). A 2-0 braided absorbable suture (Vicryl; Ethicon, Somerville, NJ) was double looped, pulled through the incision, below and above the waist of the inflated angioplasty balloon and secured (Fig. 1e to h) to create a stenosis in the outflow vein (Fig. 1i).
PMC6319522_02
a Evidence of steal syndrome with associated tissue ulceration at the fingertips. b Diagnostic fistulogram performed through a catheter placed in the inflow brachial artery shows rapid shunting of flow across the AVF into the outflow cephalic vein (arrows indicating flow direction). The radial and ulnar arteries in the forearm are poorly opacified. c Percutaneous AVF banding was performed over a 5 x 40 mm angioplasty balloon with (d) a stenosis created in the outflow vein (black arrow). Perfusion to the forearm was improved but the distal radial and ulnar arteries (white arrows) were occluded secondary to underlying atherosclerosis and the perfusion to the hand did not improved significantly in this case
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PMC6319522_02_42155_2018_35_Fig2_HTML.jpg
Fig2
An 80-year-old female patient on long term haemodialysis due to diabetic nephropathy presented with a two-week history of left hand paraesthesia, weakness, ulceration and necrosis of her fingertips on the side of a left brachiocephalic AVF (Fig. 2a). A diagnostic fistulogram was performed which demonstrated very brisk flow across the AVF with poor opacification of the radial and ulnar arteries in the forearm (Figs. 2b and c). She proceeded to undergo percutaneous AVF banding using the same technique described in the case above (Figs. 2d and e). However, despite successful flow reduction through the AVF and some improvement of arterial flow to the level of the forearm, the distal perfusion to the hand remained poor due to underlying atherosclerosis with occlusion of the distal radial and ulnar arteries and absence of the palmar arch in the hand (Fig. 2f).