A 52-year-old man was on long term haemodialysis following a failed renal transplant. Non-maturing left radiocephalic and brachiocephalic arteriovenous fistula (AVF) initially created were abandoned. He underwent hemodialysis via a right brachiocephalic arteriovenous graft (AVG) but required multiple interventions to maintain patency. During a thrombolysis procedure, venoplasty of a cephalic arch occlusion resulted in a focal rupture for which conservative management with balloon tamponade was unsuccessful. An 8 × 60 mm Fluency SG (Bard, NJ, USA) was deployed in the cephalic arch to manage the rupture. Following deployment, the SG showed no protrusion into the subclavian vein (Fig. 1). On a subsequent venoplasty procedure 5 months later, the central end of the stent had migrated into the subclavian vein resulting in jailing of the axillary vein with consequent occlusion of that segment (Fig. 1). The patient remained asymptomatic. After further interventions over a two-and-a-half year period, this AVG was eventually abandoned.
A new left loop brachiobasilic AVG was created inadvertently and the patient developed left arm swelling 2 days post-surgery. A graftogram showed complete occlusion of the axillary-subclavian vein from the migrated cephalic arch SG. Attempts to cross the axillary vein occlusion using 0.035″ standard guide wires, 0.018″ glide wires (Terumo, Tokyo, Japan), a 0.014″ Winn 200 T (Abbott Vascular, CA, USA) and 0.018″ Victory 25 g (Boston Scientific, MA, USA) CTO wires were all unsuccessful due to the inability to traverse the fabric of the Fluency SG (Fig. 2). Due to the steep angulation, sharp recanalization was not attempted in view of potential injury to the subclavian artery.
In view of the limited access options, a further attempt was made using the TruePath CTO drilling device. Under ultrasound guidance, 6F and 4F sheaths were inserted into the left common femoral vein and the venous limb of the left AVG respectively. Venography revealed a 2 cm subclavian vein occlusion adjacent to the central end of the migrated SG (Fig. 2). Attempted retrograde crossing of the occluded segment was unsuccessful and complicated by self-limiting guidewire perforations.
Via a 21G micropuncture needle (Cook Medical, IN, USA), the peripheral end of the occluded SG was accessed (Fig. 3). Using a V18 Control wire (Boston Scientific), luminal traversal of the occluded SG and subclavian vein segment was achieved. The V18 wire was snared via the left common femoral sheath using a looped 0.025″ Glidewire (Terumo, Tokyo, Japan) to achieve through-and-through access. Thereafter, a 10 × 40 mm Advance LP (Cook Medical, IN, USA) angioplasty balloon was inflated within the recanalised SG to serve as a subsequent target. Via the AVG 4F sheath, using co-axial support of a 4F Berenstein catheter (Cordis, CA, USA) and a 0.018″ CXI support microcatheter (Cook Medical, IN, USA), the TruePath CTO drilling device was advanced along the basilic and axillary vein up to the point of occlusion. Under orthogonal fluoroscopic guidance (Fig. 4), the SG ePTFE fabric was penetrated with the TruePath drilling tip towards the inflated Advance LP balloon. Rapid deflation of the punctured balloon indicated successful SG entry (Fig. 5). The TruePath wire tip, now within the ruptured balloon, was advanced centrally with the balloon in tandem. Thereafter, the CXI support catheter was tracked over the TruePath wire and exchanged for a 300 cm V18 Control wire. The balloon was then removed via the left CFV sheath and the V18 Control wire was snared out. Via the femoral sheath, the 5 × 40 mm Sterling balloon was used to pre-dilate the axillary-subclavian occlusion as well as the SG fabric (Fig. 6). Also, via the femoral sheath, vessel preparation was performed with a 7 × 40 mm Mustang balloon (Boston Scientific) followed by a 7 × 40 mm Supera stent (Abbott Vascular, CA, USA) which was deployed across the recanalised subclavian segment, through the SG and into the axillary vein. Completion angiography showed no residual stenosis or recoil of the newly stented segment (Fig. 6).
Left arm swelling improved significantly over the 3 days. Unfortunately, late infection of the AVG developed and was explanted 28 days post intervention. New long-term AVG dialysis access was created in the left lower limb. Six months after left subclavian-axillary vein stenting, an opportune catheter angiogram via his left groin AVG demonstrated continued patency, and without recoil, of the stented segment (Fig. 6).
