CASE 618 Published on 05.10.2000

Combined arterial and venous occlusion in a hemodialysis fistula treated by PTA

Section

Interventional radiology

Case Type

Clinical Cases

Authors

D. Vorwerk

Patient

54 years, male

Clinical History
Segmental thrombosis of a native hemodialysis fistula and additional arterial occlusion of the feeding radial artery
Imaging Findings
Patient presented with occlusion of a hemodialysis fistula on his left forearm. Clinically, a pulsation was still palpable at the site of the anastomosis but in the draining vein, a short segment of a tight noncompressible vein was palpated while the distal segments of the vein were compressible but without substantial filling.
From these findings, diagnosis of partial venous thrombosis was made. Diagnostic angiography was performed by retrograde puncture of the left brachial artery using a 22 G fine sheath needle. Angiography revealed an occluded proximal radial artery, a patent ulnar artery with retrograde flow across the palmar arch into the arteriovenous anastomosis and drainage via tiny collateral veins but no regular outflow through the forearm cephalic vein (Fig. 1) stating the segmental thrombosis of the proximal venous segment. As an additional diagnosis, occlusion of the radial artery was detected.
Discussion
After retrograde puncture of the cephalic vein in a thrombus-free segment, the occluded segment was passed by use of a 5 F angulated catheter proving additional stenosis close to the arteriovenous anastomosis. A 0.035 in coated guidewire was carefully introduced into the occluded segment of the radial artery. Angiography proved that the occluded segment was rather short. A 4 mm balloon was used to dilate the artery. Then, a 6 mm high-pressure balloon was used to dilate the venous segment with a pressure of 15 atm. After PTA, both the arteral occlusion and the venous obstruction was recanalized with high outflow into the cephalic vein (Fig. 2). Some small residual thrombi are still visible remaining on the venous wall. No shunt reobstruction occurred within a follow-up period of three months. Diagnosis of shunt problems may be made either by a retrograde venous access or via a transbrachial fine needle angiography. This is our routine approach especially in difficult cases to achieve a complete overview both over the arterial and the venous situation. Using fine needles it is safe, easy to apply and allows imaging during all steps of an intervention via an independent access. Shunt stenosis and thrombosis are the most frequent complications in arteriovenous fistulas. Percutaneous intervention have been shown to be successful in recanalization. For longer segment thrombosis, aspiration, thrombolysis or mechanical thrombectomy with different devices have been used showing a high efficacy in restoring blood flow. In short thrombosis however, balloon dilation alone is a cost-effective and easy tool for recanalization. Additional arterial occlusion is comparably rare in dialysis fistulas but may be successfully managed by PTA if the occluded segment remains short.
Differential Diagnosis List
Balloon dilation to be successful in recanalizing both the arterial and venous obstruction
Final Diagnosis
Balloon dilation to be successful in recanalizing both the arterial and venous obstruction
Case information
URL: https://eurorad.org/case/618
DOI: 10.1594/EURORAD/CASE.618
ISSN: 1563-4086