Fig. 1

66-year old male on hemodialysis with multiple failed prior access sites and massive arm swelling. He had a poorly functioning right transposed brachiocephalic fistula with high venous pressures and prolonged bleeding after needle decannulation secondary to chronic brachiocephalic occlusion. A Initial IR clinic visit showing right arm swelling. B Initial venograms performed through the right brachiocephalic fistula and the superior vena cava showing chronic occlusion of the brachiocephalic vein (arrow). C Left anterior oblique vein during triangulation of PowerWire (tip shown with arrow) across the occlusion toward the snare in the superior vena cava. D Capture of the PowerWire with the snare. E Balloon dilation of the brachiocephalic occlusion to 14 mm (performed following serial dilation from 6/10/12 diameter balloons, with interval venograms). F Venography during positioning of a 13 mm × 50 mm PTFE-lined stent graft (Viabahn, Flagstaff, AZ) across the site of elastic recoil following 14 mm venoplasty. G Completion venogram following stent deployment and post dilation with a 14 mm balloon. H IR clinic visit at 4 weeks following interval resolution of both arm swelling and access site dysfunction