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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 48-50

Successful endovascular recanalization of a thrombosed arteriovenous fistula with extensive stenosis: A case report


1 Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
2 Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14th Floor K Block, Queen Mary Hospital, Hong Kong, China
3 Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China; Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China

Date of Submission26-Nov-2021
Date of Decision28-Jan-2022
Date of Acceptance30-Jan-2022
Date of Web Publication27-May-2022

Correspondence Address:
Dr. Hai-Lei Li
Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2589-9686.346192

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  Abstract 


Management of chronic arteriovenous fistula (AVF) thrombosis is challenging. In this case report, we described successful endovascular treatment for a thrombosed AVF with extensive stenosis. A 50-year-old woman presented with diminishing blood flow of her forearm AVF. Diagnostic angiogram showed a long segment of cephalic vein outflow stenosis, occlusion of one accessory cephalic vein branch, and proximal stenosis of the cephalic vein. After angioplasty, the occluded fistula was recanalized without any significant residual stenosis. The AVF had been functional at 6-month follow-up.

Keywords: Arteriovenous fistula, balloon angioplasty, hemodialysis access, stenosis, thrombosis


How to cite this article:
Li HL, Chan YC, Pai P, Cheng SW. Successful endovascular recanalization of a thrombosed arteriovenous fistula with extensive stenosis: A case report. Vasc Invest Ther 2022;5:48-50

How to cite this URL:
Li HL, Chan YC, Pai P, Cheng SW. Successful endovascular recanalization of a thrombosed arteriovenous fistula with extensive stenosis: A case report. Vasc Invest Ther [serial online] 2022 [cited 2022 Dec 5];5:48-50. Available from: https://www.vitonline.org/text.asp?2022/5/2/48/346192




  Introduction Top


Autogenous arteriovenous fistula (AVF) is the optimal hemodialysis access compared with prosthetic graft and central venous catheter, as AVF has a better patency rate and fewer complications, including thrombosis and infection. Successful AVF formation is a challenge in end-stage kidney disease (ESKD) patients with diabetes mellitus (DM) because of the nature of the blood vessels. Stenosis and thrombosis are the most common complications after autogenous AVF creation.[1] Surgical and endovascular are two approaches for the management of thrombosed AVF. Up to date, there is limited evidence in the literature to demonstrate which technique has a better clinical outcome. We reported the successful revascularization of a thrombosed AVF in a 50-year-old diabetic patient with multisystem disease, including dermatomyositis and systemic lupus erythematosus (SLE).


  Case Presentation Top


The case referred to a 50-year-old ESKD woman who suffered from Type II DM, hypertension, dermatomyositis, and SLE and was on long-term prednisone. She started on peritoneal dialysis 5 years ago because her forearm veins were deemed to be too small for a native AVF. However, she developed peritonitis a year later, and a left radiocephalic AVF was created. The patient had been on hemodialysis via AVF for more than 3 years.

The patient presented to our clinic as the blood flow of her AVF was diminishing and becoming suboptimal on hemodialysis. The thrill of the AVF was weak on physical examination. Extensive fistula stenosis and suspected segmental thrombosis were identified on duplex ultrasound. Diagnostic angiogram was performed under local anesthesia. The left brachial artery was punctured under ultrasound guidance, and a 6-Fr introducer sheath was inserted. Angiogram showed a long segment of the cephalic vein outflow stenosis, occlusion of one accessory cephalic vein branch, and cephalic arch stenosis [Figure 1]. A 0.035” guidewire was passed successfully through the stenosed cephalic vein and its occluded branch. Angioplasty was performed using a 5 mm × 40 mm balloon (Passeo, Biotronik, Lake Oswego, US), then followed by a 5 mm × 120 mm drug-coated balloon (DCB, Orchid, Acotec, Beijing, China). On completion, angiogram showed that the occluded accessory vein was recanalized without any significant residual stenosis [Figure 2]. The thrill improved after the intervention, and the AVF had been functional at 6-month follow-up.
Figure 1: The wrist arteriovenous fistula anastomosis appeared reasonable (left panel), but one of the outflow cephalic accessory veins was thrombosed with extensive stenosis of the outflow cephalic vein

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Figure 2: On completion, angiogram showed the occluded accessory vein had been successfully recanalized and the stenosis also improved significantly

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  Discussion Top


In this case report, we described successful endovascular treatment for a dysfunctional AVF, with extensive stenosis and thrombosis in this female patient with SLE, Type II DM, and dermatomyositis. The choice between hemodialysis and peritoneal dialysis in patients with SLE remains controversial. This woman was initially on peritoneal dialysis as the forearm veins were anatomically unsuitable for AVF creation and then complicated with peritoneal infection. Preoperative duplex ultrasound vein mapping was routinely performed in our practice. Radiocephalic AVF was our first choice to preserve the proximal vein. The diameter of cephalic vein increased from 1.5 mm to 2.0 mm after muscle exercise and subsequently underwent radiocephalic AVF placement. SLE patients on hemodialysis had a higher risk of vascular access thrombosis compared with non-SLE patients; two-thirds of patients with SLE developed vascular access thrombosis at 1 year.[2] Surgical and endovascular approaches are established treatment for failing and thrombosed AVFs. Endovascular intervention has gained popularity in the past decade as it is less invasive and could be repeatable to preserve the native vessel. A systematic review suggested that the result of surgical and endovascular treatment for thrombosed vascular access was comparable.[3] The current Society for Vascular Surgery guidelines recommends both open surgery and endovascular techniques to maintain or restore the patency of nonfunctional or failed AVFs.

Angioplasty with high pressure or cutting balloon has been the treatment of choice for AVF stenosis. DCB delivering paclitaxel has shown superiority in coronary and peripheral arterial disease. Currently, there are few data regarding the use of DCB in AVF stenosis. In a systematic review, the use of DCB was associated with higher primary patency compared with uncoated balloon at 6 months.[4] In a randomized trial comparing drug-eluting balloon angioplasty with conventional angioplasty for hemodialysis access stenosis, Irani et al.[5] reported that drug-eluting balloon was effective in prolonging primary patency at 6 and 12 months. Despite the improved outcomes of percutaneous transluminal angioplasty for failing AVFs, it should be noted that the rate of restenosis and re-intervention after primary angioplasty remains high. Thus, large-scale study with long-term follow-up is necessitated to evaluate the clinical outcome of balloon angioplasty for thrombosed AVFs.

Informed consent

Informed consent has been obtained from the patient for publication of the case report and accompanying images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mickley V. Stenosis and thrombosis in haemodialysis fistulae and grafts: The surgeon's point of view. Nephrol Dial Transplant 2004;19:309-11.  Back to cited text no. 1
    
2.
Shafi ST, Gupta M. Risk of vascular access thrombosis in patients with systemic lupus erythematosus on hemodialysis. J Vasc Access 2007;8:103-8.  Back to cited text no. 2
    
3.
Tordoir JH, Bode AS, Peppelenbosch N, van der Sande FM, de Haan MW. Surgical or endovascular repair of thrombosed dialysis vascular access: Is there any evidence? J Vasc Surg 2009;50:953-6.  Back to cited text no. 3
    
4.
Khawaja AZ, Cassidy DB, Al Shakarchi J, McGrogan DG, Inston NG, Jones RG. Systematic review of drug eluting balloon angioplasty for arteriovenous haemodialysis access stenosis. J Vasc Access 2016;17:103-10.  Back to cited text no. 4
    
5.
Irani FG, Teo TK, Tay KH, Yin WH, Win HH, Gogna A, et al. Hemodialysis arteriovenous fistula and graft stenoses: Randomized trial comparing drug-eluting balloon angioplasty with conventional angioplasty. Radiology 2018;289:238-47.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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