Clinical problem: A  43-year-old male patient with end-stage renal disease was referred to the interventional radiology service for a new dialysis access and relief of signs of superior vena cava syndrome. He had had many failed autogenous and non-autogenous arteriovenous accesses, and recently reverted to tunneled dialysis catheters as he waited for new arteriovenous access. Most recently, he suffered cardiac arrest at another facility while receiving a tunneled dialysis catheter.

Angiographic findings: There is chronic total occlusion of the distal right internal jugular vein (RIJV), right external jugular vein (REJV), right brachocephalic vein (RBCV), and the superior vena cava from previous catheterizations. The occlusions prevent the insertion of a new catheter by conventional means. Other findings from other imaging modalities revealed occlusions of the common femoral and iliac veins as well as the SVC.

Endovascular interventions: The distal right internal jugular vein was identified with a high-frequency ultrasound probe and accessed with a micropuncture set. Venogram through the access revealed complete occlusion of the distal end of the vein as well as collaterals at the root of the right neck. It was not possible to pass a guidewire through the access into the right atrium, so a second access was gained into the right external jugular vein under ultrasound guidance. Central venogram through this access showed it was also completely occluded, but it was possible to probe through it into the right atrium with a stiff guidewire and a catheter. With the stiff guidewire advanced through this access into the inferior vena cava, a balloon was used to dilate the occluded venous track. After confirming that the lumen of the vessel was restored, a double-lumen, cuffed catheter was advanced into the right atrium and retrogradely tunneled through the upper right chest and out the skin. The final chest radiograph shows the well-curved catheter in the right atrium. 

Practical points:

1. It is possible to recanalize chronic venous occlusions, even when such prospect seems bleak.
2. Such occlusions result from previous central venous catheterizations or manipulations. The presence of cardiac electrodes through the right subclavian vein in this patient did not help matters.
3. Such occlusions when bilateral and total can cause superior vena cava syndrome, whose symptoms may be pronounced by fluid retention when the occlusions preclude dialysis and there no other means for dialysis. 
4. Recanalizing such occlusions can be life-saving when there are no other ways to dialyze a patient.

Clinical problem: 44-year-old man who had had multiple failed arteriovenous accesses in the past. His new left forearm non-autogenous brachiobrachial access did not work well at his most recent hemodialysis session.

Findings at imaging: The angiogram shows a loop arteriovenous graft connecting the distal left brachial artery to the proximal left brachial vein. The artery, the graft, and the vein are patent, the vein yet to mature. A large aneurysm overlays the distal left brachial artery, obscuring the arterial anastomosis of the graft and the effect of the aneurysm, if any, on the juxta-anastomotic graft. Axial color Doppler view of the aneurysm confirms a massive, swirling structure with a turbulent interior. The arrow at its 11:00 position identifies the juxta-anastomotic segment of the graft, partially collapsed by the aneurysm.

Intervention: The patient was referred to vascular surgery for aneurysmectomy, which corrected the problems at dialysis. The mass proved to be a pseudoaneurysm of the distal brachial artery thought to be iatrogenic.

Clinical problem: Failed right brachiobrachial fistula.

Angiographic findings:

1. A high-grade juxta-anastomotic venous stenosis.
2. 2 upstream venous aneurysms between which is sandwiched  a 2nd high-grade venous stenosis.
3. A 3rd venous stenosis, also high-grade, distal to the distal aneurysm.
4. Venous collaterals around the right axillary vein due to chronic total occlusion of the right subclavian vein.

Challenges: Many lesions clustered within a short venous segment with little room for intervention. Accessing the normal downstream brachial vein was difficult because there wasn’t much room between the patient’s chest wall and the right arm.

Intervention: 

1. The proximal right brachial vein was accessed with ultrasound guidance, the needle pointing towards the central veins, and the access secured with a sheath.
2. A balloon was advanced to the distal venous stenosis and inflated, eliminating the stenosis.
3. A second access was secured into the downstream brachial vein, pointing towards the right hand, through which the balloon was passed to the juxta-anastomotic and inter-aneurysmal stenoses and inflated.
4. Reflux angiography of the access circuit was performed and revealed normal arterial limb of the circuit.
5. Final angiography of the venous limb of the circuit revealed resolved stenoses.
6. No action was taken on the aneurysms at this session.
7. The subclavian occlusion was not addressed because it did not seem to contribute to the failure of the access.