A 64-year-old male patient had been treated by HD in the last 5 years via right brachiocephalic fistula (BCF). He presented with gradually increasing painful swelling of the right upper limb, a sign of VH. He was evaluated with CT angiography and documented to have right internal jugular vein (IJV) stenosis with extensive collaterals in upper limb [].\nUnder all aseptic precautions, right IJV access was secured with 7 Fr sheaths. 5 Fr KMP catheter was used to negotiate across the IJV stenosis over a guide wire. A 10 mm × 40 mm balloon dilator was deployed across the stenosis and dilatation done. 14 mm × 40 mm self-expandable stent was passed across the stenosis. Poststent check angiogram revealed few collaterals still persisting around the stenotic site []. The AVF was cannulated via radial artery and fistulogram done revealing multiple stenosis along the whole length of the cephalic vein which were dilated sequentially from central to the peripheral. The venogram revealed persistent stenosis in IJV proximal to the level of the stent already in situ. Another 14 mm × 40 mm self-expandable stent was deployed proximal to the first one and final check angiogram revealed good direct flow in central vein []. AE of the peripheral collaterals near the anastomotic site was also done to give a further advantage.
A 34-year-old male patient had been treated by HD in the last 3 years via left brachiocephalic AVF. He presented with gradually increasing painful swelling of the left upper limb, a sign of VH. He was evaluated with CT angiography and documented to have stenosis at IJV and left brachiocephalic vein. Under local anesthesia, the right common femoral artery access was secured with a 5 French sheath. Using 5 French H1 catheter and hydrophilic guide wire, left brachial artery angiogram was performed. The left common femoral venous access secured. However, H1 catheter could not be negotiated into left brachiocephalic vein (the angiogram also confirmed the presence of an occlusion in left brachiocephalic vein. Echelon – 10 and traxcess for guide wire was placed within the venous side of AVF. A 6 × 20 microplex 18 coil was placed in the venous side. Subsequently 5 × 15 (GDC – 18) and 4 × 10 (GDC – 10) coils were placed within the venous side of a fistula, followed by introduction of fibrin glue, 1 ml (1:2 dilution). Final check angiogram revealed closure of AVF. Right lower limb was immobilized for 6 h and left upper limb raised. Limb edema disappeared in 48 h [].