PMC6298902_01
A schematic illustration of the PTA technique and the one-sheath inverse method. (A) Insertion of a sheath in the cephalic vein around the middle of the right forearm toward the anastomosis side by the Seldinger technique. (B) Retrograde angiography showing venous stenosis 0-4 cm from the site of anastomosis (arrowheads), (C) under PTA and (D) post-PTA. Black arrow indicates the puncture point. (E) Antegrade angiography showing stenosis of the median cubital vein (length, approximately 6 cm; white arrows). (F) A dilator and guidewire were threaded into the sheath, and (G) the guidewire was placed in the vein. (H, I) The coaxial dilator/sheath was pulled and gradually stood, and (J) the tip of the dilator/sheath was slightly inverted toward the downstream side. (K) While keeping the state of (J), the distal end of the guidewire was pulled around the tip of the dilator, inverted toward the downstream side, and navigated. (L, M) The coaxial dilator/sheath was carefully reinserted into the vein over the guidewire, and the guidewire and dilator were removed from the sheath. (N) Images showing stenosis of the median cubital vein, (O) under PTA, and (P) post-PTA. In angiography, the upper side reveals the heart side and the lower side reveals the anastomosis side. PTA: percutaneous transluminal angioplasty, RA: radial artery.
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PTA was successfully performed as a salvage operation (Fig. 1A-P). K. K., Tokyo, Japan) in the cephalic vein around the middle of her right forearm toward the site of anastomosis by the Seldinger technique (Fig. 1A). Retrograde angiography from the vein under avascularization revealed venous stenosis 0-4 cm from the site of anastomosis (Fig. 1B). After 2000 units of heparin were administered and allowed to circulate for 5 min, we dilated the lesion several times at 4-18 atm for 30 s, and retrograde angiography showed the improvement of stenosis (Fig. 1C,D). First, we detected the stenosis (length, approximately 6 cm) of the median cubital vein by antegrade angiography (Fig. 1E). A dilator and guidewire were threaded into the sheath (Fig. 1F), and the guidewire was placed in the vein (Fig. 1G). Next, the coaxial dilator/sheath was pulled and gradually stood (Fig. 1H,I), and the tip of the dilator/sheath was slightly inverted toward the downstream side (Fig. 1J). While maintaining this state, the distal end of the guidewire was pulled around the tip of the dilator, inverted toward the downstream side, and navigated (Fig. 1K). The coaxial dilator/sheath was carefully reinserted into the vein over the guidewire and the guidewire and dilator were removed from the sheath (Fig. 1L,M). We confirmed the stenosis of the median cubital vein by antegrade angiography again (Fig. 1N). The guidewire and balloon catheter could pass through the lesion; we then dilated the lesion several times at 2-10 atm for 30 s (Fig. 1O). As angiography showed the improvement of stenosis (Fig. 1P), we removed the sheath and finished the procedure.
A schematic illustration of the arteriovenous fistula in the patient's right forearm.
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A schematic illustration of her AVF in the right forearm is shown in Fig. 2.