Clinical problem: Failed right brachiobrachial fistula.
- A high-grade juxta-anastomotic venous stenosis.
- 2 upstream venous aneurysms between which is sandwiched a 2nd high-grade venous stenosis.
- A 3rd venous stenosis, also high-grade, distal to the distal aneurysm.
- 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.
- The proximal right brachial vein was accessed with ultrasound guidance, the needle pointing towards the central veins, and the access secured with a sheath.
- A balloon was advanced to the distal venous stenosis and inflated, eliminating the stenosis.
- 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.
- Reflux angiography of the access circuit was performed and revealed normal arterial limb of the circuit.
- Final angiography of the venous limb of the circuit revealed resolved stenoses.
- No action was taken on the aneurysms at this session.
- The subclavian occlusion was not addressed because it did not seem to contribute to the failure of the access.