1Melek Ben Mrad, 1Boutheina Ben Abdellatif, 2Lilia Ben Fatma, 3Imtinen Ben Mrad, 1Rim Miri, 1Sobhy Mleyhi, 2Ikram Mami, 1Raouf Denguir
1Cardiovascular Surgery Department, The Rabta Hospital, Tunis, Tunisia; 2Nephrology Department, The Rabta Hospital, Tunis, Tunisia; 3Cardiology Department, Habib Thameur Hospital, Tunis, Tunisia
Stenosis of the cephalic arch is common problem in the fellow up of brachiocephalic arteriovenous fistula, and it is usually treated firstly with balloon angioplasty. Early recurrent restenosis is also a common problem that requires sometimes stenting to prevent thrombosis.
The long-term risk of stenting in such tortuous region is the fracture of stent.
A 49-year-old female with end-stage renal disease (ESRD) with a right upper extremity brachiocephalic fistula presented with mild swelling of her right upper extremity. Two years previously, she underwent placement of a balloon expandable stent (Express, Boston Scientific) in the cephalic arch for severe recoil during angioplasty.
US Duplex showed decrease of the fistula flow, with severe stenosis of the cephalic arch and the subclavian vein.
After fistula puncture, first angiogram showed a total fracture of the old stent with migration of the proximal part of the stent in the humeral vein. After several attempts, we succeed to cross intraluminally the two segments of the old stent. We had a rupture of the first balloon during its inflation, so we have used a 7 mm scoring balloon to dilate the cephalic arch and the subclavian vein. After prolonged inflation, we were able to have an acceptable result with a residual stenosis less than 40%. We decided not to put a covered stent in order to avoid thrombosis of the humeral vein.
Doppler control was good, with reappearance of a good thrill and reduction of oedema in the following days.
Despite the relative success of this intervention, we believe that stenting of the cephalic arch in arteriovenous fistula is not recommended. Fracture of the stent is a serious complication that is very difficult to manage, and which can lead to thrombosis of the entire venous axis of the upper limb.