A 79-year-old woman with ESRD and a positive COVID-19 test on maintenance hemodialysis presented to the emergency department after multiple failed attempts to cannulate her left upper extremity AV graft. The patient had potassium of 5.2 on admission and did not have any signs of volume overload or uremia to suggest the need for urgent hemodialysis. Physical examination of the left upper extremity was significant for the absence of any thrill or pulsatility along the course of the AV graft suggestive of graft thrombosis. Given the patient’s COVID-19 positive status, the decision was made to admit the patient in observation status and perform a graft thrombectomy. Due to the patient’s contrast allergy, an overnight 13-h steroid regimen was administered and the procedure was performed the following morning. The patient was brought to the IR suite and the left arm was prepped and draped in a sterile fashion. A limited ultrasound of the left arm AV graft showed separation of the graft fabric layers with thrombus in the false lumen between the superficial fabric layer and delaminated layer as well as a thrombus in the “true” lumen between the delaminated layer and the deep fabric layer (Fig. 1a, b). Under the fluoroscopic guidance, a micropuncture needle was inserted into the graft in an antegrade fashion near the graft artery anastomosis and a 0.018″ wire was advanced through the needle but was unable to be advanced beyond the midportion of the graft. Ultrasound-guided micropuncture needle access was obtained in a retrograde fashion, however again an 0.018″ wire was unable to be advanced beyond the midportion of the graft (Fig. 2a). This occurred due to a micropuncture sheath being within the delaminated portion of the graft instead of the proper lumen.
The micropuncture needles were exchanged over the 0.018″ wires for micropuncture upsizing sheaths. Attempts were made to advance 0.035″ glide wires (Terumo Corp; Tokyo, Japan) without success. The contrast was then injected from the antegrade and retrograde upsizing sheaths demonstrating access within the delaminated false lumen which showed a thin “tail” of contrast emptying into a widely patent native axillary vein.
Transfemoral access was then obtained via the left common femoral vein and an 8 Fr sheath was placed. A 5 Fr angled catheter was advanced over a glide wire (Terumo Corp; Tokyo, Japan) and was used to cross the graft vein anastomosis and gain access into the true lumen of the graft. A contrast injection demonstrated patency of the graft beyond the area of delamination without evidence of venous anastomosis stenosis (Fig. 2b).
A 3.2 Fr 4–8 mm En-Snare (Merit Medical; South Jordan, Utah) was advanced through the antegrade upsizing sheath and was used to capture the glide wire providing through and through access in the true lumen (Fig. 2c). The upsizing sheath was exchanged over the wire for a 7Fr sheath and balloon angioplasty of the graft was performed using an 8 mm Mustang angioplasty balloon (Boston Scientific, Marlborough, MA) showing a recurrent moderate to severe waist in the midportion of the graft (Fig. 2d).
Under ultrasound guidance, the graft’s true lumen was then re-accessed in a retrograde fashion and a 6 Fr sheath was placed. Balloon angioplasty and platelet plug embolectomy of the graft artery anastomosis was performed with a 5 mm Mustang angioplasty balloon (Boston Scientific, Marlborough, MA). A brachial arteriogram was then performed which showed restoration of arterial flow through the graft. A focal area of extra-luminal contrast was identified (Fig. 3a) correlating to the area of fabric delamination. Via the retrograde access, an 8 mm × 50 mm Gore Viabahn Endoprosthesis (Gore Medical; Newar, DE) was deployed across the area of delamination and post dilated with an 8 mm angioplasty balloon. A completion brachial arteriogram demonstrated brisk flow through the graft with the resolution of the previously seen area of delamination (Fig. 3b).
Since the completion of the procedure, the patient has undergone 36 successful hemodialysis sessions, which signifies that the fistula has been successfully salvaged.