Endovascular revascularization of “swing segment” basilic vein stenosis in patient with failing arteriovenous hemodialysis fistula: case report

Swing segment stenosis of basilic vein is a frequent complication in hemodialysis patients with brachial- basilic arteriovenous fistula (AVF) with overall prevalence up to 45% and significant impact on functionality of AVF, thus increasing hospitalization and failed hemodialysis rate. In history “ swing point” stenosis were treated with cutting ballons or balloon-expandable stentgraft, but early restenosis was frequently noted. A covered self- expandable stentgraft may prevent or limit restenosis related to intimal hyperplasia, but also can adapt to mobility of the arm thus decreasing the rate of stentgraft fracture. A case report: 30 year old woman with diabetes mellitus (type I) and secondary end-stage chronic renal disease (ESRD) with previous history of failed femoral and right jugular hemodialysis catheter and occluded right subclavian vein underwent brachial- basilic AVF operation in left arm. After only one successful hemodialysis through AVF brisk arterial backflow was noted during AVF puncture leading to failure of procedure. CT angiography revealed stenosis of proximal basilic vein. Upper extremity swelling was absent. Ultrasonography showed wall thickening of proximal basilic vein and turbulent blood-flow on duplex ultrasound. The digital substraction angiography approved the diagnosis of swing segment stenosis of 80% in basilic vein. Transvenous/ transfemoral angioplasty of left basilic vein was performed through 10F sheath guiding catheter with new generation of AVF dedicated self-expandable covered stentgraft 12x60mm. Flexion test of the arm also performed on operation table showing good adaptation of the stent to the vessel wall. In result next hemodialysis session through AVF was successful and uneventful. Poorly functioning AVF frequently have impaired outflow vein at the surgical vein mobilization site. These "swing point stenoses" can be effectively treated by PTA with new generation of self-expandable stentgrafts, which is a safe and effective treatment for prolonging AVF patency and function.