PMC5692143_01
(a) Venography of the AVF by direct puncture of the juxta-anastomotic vein during manual compression of the brachial artery: regular patency of the arteriovenous anastomosis and the occlusion of the cephalic vein above the anastomosis. Main drainage through the basilic vein (arrow). Dashed line: schematic representation of the occluded cephalic vein. (b) Fistulography showing vasospasm of the high takeoff radial artery, occlusion of the graft's arterial inflow (arrow) and the patency of the "early cannulation" graft. (c) Volume rendering CTA 4 months after trans-anastomotic Viabahn stent graft (Gore, Flagstaff, USA) (arrow) release showing circuit patency. High takeoff of the radial artery from the axillary artery is clearly depicted (arrowhead). Patency of the ulnar and interosseus artery to the forearm from the brachial artery. Residual stenosis at the graft-vein anastomosis, treated 1 month later (star).
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Diagnostic angiography showed a patent arteriovenous (AV) anastomosis and perianastomotic vein and chronic occlusion of a long segment of the cephalic vein (Figure 1(a)). US-guided phlebography showed low flow along the graft (Figure 1(b)). It revealed a stenosis on the cephalic arch, which was treated by PTA with drug eluting balloon 1 month later (Figure 1(c)).
PMC5692143_02
(a) Completion venography after first endovascular reintervention. Restored flow along the venous axis through a new Viabahn stent graft (arrowheads) overlapping the old stent graft (stars), no residual thrombus in the efferent basilic vein (arrow). (b) After 3 months: angiography through the occlusion of the second Viabahn stent graft in correspondence of the proximal edge of the first one (arrow). Some encroaching of the Nitinol mesh seems appreciable. Floating thrombus extended above the elbow in the basilic vein (star). (c) Schematic drawing illustrates final situation: removal of the stent grafts (arrowhead) and surgical implantation of a PTFE bridge (arrow) on the venous line preserving the native arteriovenous fistula (early cannulation graft was not available). Stars indicate the available native areas for HD venipuncture during graft maturation.
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The thrombus was aspirated percutaneously and a new stent graft (8 mm x 100 mm) was placed overlapping the previous one (Figure 2(a)) gaining AVF's thrill. Phlebography revealed complete occlusion of the stent grafts with an extended thrombosis of 14 cm along the basilic vein above the elbow (Figure 2(b)). During the graft maturation time, HD puncture was allowed on the proximal and distal vein segments (Figure 2(c)).