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Patient initials or identifier number
Relevant clinical history and physical exam
A 33-year-old man came for a 12-hour history of totally occluded arteriovenous fistula (AVF).
Past history: polycystic kidney disease with regular hemodialysis since childhood and active smoker.
Physical examination: a radiocephalic forearm AVF with signs of total occlusion (no pulsation, bruits, or thrills). There was a large aneurysm of 4 cm in diameter at the proximal vein. Palpation noted no bruits nor thrills.
Relevant test results prior to catheterization
The patient came for emergent arteriovenous fistula angiography. The angiography procedure for a malfunctioning arteriovenous fistula in our cath lab did not require routine laboratory examination unless the patient presented with fever or signs of infection at AVF.
Relevant catheterization findings
Vascular access: a retrograde puncture at forearm cephalic vein with a 20 GA IV catheter. A 7-Fr sheath was placed.
Diagnostic fistulogram: total occlusion of radiocephalic AV fistula. A large aneurysm with calcification located at the proximal vein near the AV junction (fig1). The retrograde approach failed due to difficulty in probing the exact location of AV junction. Antegrade approach was established by direct brachial puncture and placement of a 6-Fr sheath (fig2 and fig3).
1. Retrograde approach: a 6x20 FoxCross balloon advanced retrogradely via a 0.035-inch GlideWire. Failed to probe the AV junction.
2. Antegrade approach: a 6-Fr sheath placed in brachial artery. A 6x20 FoxCross balloon with antegrade wiring into the aneurysm.
3. Double balloon technique in the aneurysm to facilitate probing of the true lumen.
4. 0.014-inch wire from retrograde route successfully entered the radial artery.
5. Due to difficulty in advancing the retrograde 0.014-inch wire to brachial sheath, a Rendezvous technique was performed.
6. Rendezvous technique: placing a JR4 4-Fr catheter antegradely via the brachial sheath. Re-entrance of the retrograde wire into the antegrade JR4 catheter (animation: Rendezvous.mov).
7. Pull-out the retrograde wire and perform pull-through technique to facilitate positioning of the balloon in the calcified aneurysm (fig4).
8. Complete the procedure with balloon angioplasty (fig5).
In severely calcified AVF with aneurysmal change, it is difficult to recanalize and perform endovascular balloon angioplasty, especially when the AVF becomes totally occluded. Multiple techniques evolved in percutaneous coronary intervention and peripheral angioplasty is often combined to yield a good result. This allowed the patient presented with a totally occluded AV fistula to recovery the function of the hemodialysis access. When performed in experienced hands, endovascular approach provided similar efficacy of longterm patency rate with a shorter procedure time.