Teaching Case

Dysfunction of Brescia-Cimino dialysis fistula

Patient presented with dysfunction of his Brescia-Cimino lower arm fistula located on the right forearm. The fistula was created 27 months before without any other event of dysfunction or thrombosis. Palpation revealed arterial pulsation at the anastomosis and practically no flow into the venous portion. The draining cephalic vein was soft and compressible in ist proximal part indicating that no venous thrombosis had yet developed. However, the more distal venous segment was narrowed and hardened. The clinical findings indicated shunt dysfunction due to venous stenosis close to the arteriovenous anastomosis.

After retrograde puncture of the cephalic vein in a segment more close to the elbow , a 5 F catheter was inserted into the vein and advanced towards the anastomosis. Fig. 1 shows a tight venous stenosis of the cephalic vein which is so narrow that even the 5 F catheter already blocks the residual lumen. After managing an 0.035 in coated guide wire deep into the radial artery, a 6 F vascular sheath was inserted into the cephalic vein and a 5 mm 4 cm long high pressure balloon catheter (Centurion, Bard Inc.) was placed into the stenotic segment. After 45 seconds of dilation with a pressure of 20 atm, the stenosis was opened and flow was restored (Fig. 2). No balloon waist occurred during dilatation, which caused some tears in the venous wall indicating that further ballooning would risk venous rupture. Functionally, high flow was restored indicating a sufficient PTA result.