Angioplasty Induced Cephalic Arch Rupture

Special Article - Hemodialysis

Austin J Nephrol Hypertens. 2017; 4(1): 1065.

Angioplasty Induced Cephalic Arch Rupture

Quencer KB*

Department of Radiology, University of California-San Diego, USA

*Corresponding author: Quencer KB, Department of Radiology, University of California-San Diego 200 W. Arbor Drive San Diego, CA 92103, USA

Received: April 24, 2017; Accepted: May 16, 2017; Published: May 29, 2017


Per Kidney Disease Outcome Quality Initiative (KDOQI) guidelines the second most preferred dialysis access, after the radiocephalicarterio-venous fistula (AVF), is the upper arm brachiocephalic AVF. Stenosis within the cephalic arch, the central most portion of the cephalic vein, occurs in up to 75% of dysfunctional brachiocephalic AVFs. While angioplasty is the first line treatment, subsequent patency is low. Additionally, angioplasty at this site is more commonly complicated by vessel rupture than at other sites within AV accesses. We describe a case of a 76 year-old female with end-stage renal disease (ESRD) undergoing a fistula gram and angioplasty of cephalic arch stenosis that resulted in vessel rupture. It was successful treated with prolonged balloon inflation. Cephalic arch stenosis, its etiologies, treatments are briefly reviewed. Additionally, management of angioplasty induced vessel rupture during fistulography is discussed.

Keywords: Cephalic arch; Angioplasty; Vessel rupture


KDOQI: Kidney Disease Outcome Quality Initiative; AVF: Arterio-Venous Fistula; ESRD: End-Stage Renal Disease; PTFE: Polytetraflouroethylene; mm-millimeter

Case Presentation

A 76 y/o F with a past medical history of ESRD secondary to hypertension had a left upper arm brachiocephalic fistula created 15 months prior to our procedure. The AVF was first used 7 weeks after its creation. Ten weeks later, focal false aneurysm and associated hematoma developed at a cannulation site. This was treated by placement of a 6mm polytetraflouroethylene (PTFE) interposition graft. The AVF continued to work well for another 10 months but low flows, poor clearance and prolonged bleeding subsequently developed. She was therefore referred to interventional radiology for fistula gram and possible intervention.

Initial antegrade angiogram (Figure 1) showed moderate cephalic arch stenosis. After sizing the balloon to match the diameter normal caliber adjacent cephalic vein segment, angioplasty was performed with a 7 millimeter (mm) diameter high-pressure balloon (Conquest® Bard PV) (Figure 2). The balloon and wire were pulled back and a repeat angiogram showed significant extravasation at the site of angioplasty consistent with vessel disruption (Figure 3). A wire and balloon were successfully re-negotiated across this site of disruption low-pressure inflation was done for 5 minutes (Figure 4). Repeat angiogram showed cessation of contrast extravasation and good flow through the cephalic arch (Figure 5).