LAUSR

An 82-year-old woman was referred for endovascular thrombectomy of the dialysis AVG. The patient had a history of diabetes, coronary artery disease, peripheral arterial occlusive disease, and paroxysmal atrial fibrillation under therapy with clopidogrel and apixaban. The patient began undergoing hemodialysis from May 2019, initially via a central vein catheter at the left internal jugular vein. A 7-mm loop polytetrafluoroethylene AVG was created in Jan, 2020. The patient began to use the AVG for hemodialysis on May 9, 2020. After dialysis via the AVG twice, thrombosis developed without any preceding physical or hemodynamic abnormalities. Endovascular thrombectomy was performed to salvage vascular access. Before the procedure, 5000 units of heparin was administered. A 7F short sheath was placed in the arterial limb of the graft, and clots in the venous limb were fragmented with a 7-mm 4-mm angioplasty balloon (Wanda, Boston Scientific, Boston, MA, USA) and aspirated from the sheath as much as possible. Another 7F short sheath was placed in the venous limb of the graft. After passing the guidewire through the brachial artery, the arterial plug was flattened with balloon dilatation, and clots were aspirated from the sheath. On performing angiogram of the outflow veins from the arterial sheath, the flow observed was slow. The outflow vein was wired smoothly with the free advancement of the inflated angioplasty balloon to the central veins. Nonetheless, blood flow was still compromised. We tried to evaluate the outflow veins by injecting contrast from the central lumen of the angioplasty balloon, by placing it at the outflow vein. Unexpectedly, the angiogram showed that the balloon directed to the outflow vein was in the brachial artery through a B-B fistula (Figure 1). There was no significant obstruction from the graft-venous junction to outflow vein. Because the flow from the graft to the outflow vein was compromised by the competing flow from the B-B fistula, we placed the wire back into the outflow veins. A 7-mm 10-cm stent graft was deployed from the graft-venous junction to the brachial vein distal to the connection of the B-B fistula. The size of stent graft was determined by the diameter of vessel proximal to the lesion. After deployment of stent graft, no residual shunt was found in the angiography from brachial artery. A uniform brisky thrill resumed after stenting at the graft-venous junction, and the AVG has functioned well without further complications since.