Case 1
A 50-year-old man on long term haemodialysis through a left-sided brachiocephalic AVF presented with worsening pain and cyanosis in the left hand. The AVF had also become progressively aneurysmal over the preceeding 2 months. Duplex ultrasound demonstrated non-occlusive laminated thrombus in the aneurysmal outflow vein. The distal radial and ulnar arterial pulses were weak with monophasic flow demonstrated on duplex assessment. 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).
Percutaneous AVF banding was performed following ultrasound-guided retrograde access into the cephalic venous outflow limb with placement of a 6 French introducer sheath (Prelude; Merit Medical, South Jordan, UT). The brachial artery inflow was retrogradely catheterised using a 5 French angled KMP catheter (Cook, Bloomington, IN) and 0.035″ hydrophilic guidewire (Glidewire; Terumo, Somerset, NJ) combination. Following this, a 5 × 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). Immediate post-banding duplex ultrasound showed reduced velocities in the outflow vein. If there was no change on the immediate post-banding duplex study, the balloon can be exchanged for a smaller diameter balloon for creation of a smaller diameter band. In this case, there was complete resolution of DASS clinical symptoms and no issues related to dialysis or AVF thrombosis 6 months following the procedure.
Case 2
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). The radial and ulnar arterial pulses were undetectable on clinical and duplex assessment. 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). The tissue loss was managed conservatively and eventually healed with associated soft tissue atrophy over a period of 8 weeks.