From the OR | Clinical Case
Can an endovascular intervention avoid an additional access operation?
Managing dialysis access in elderly patients often presents particular challenges. Beyond long-term access function, the burden of additional procedures, individual vascular anatomy and the timely availability of a usable cannulation segment all play an important role.
The following case illustrates how targeted endovascular treatment enabled the use of an existing dialysis access without immediately resorting to a more extensive surgical revision.
Clinical situation
A patient over 80 years of age was referred to our vascular access centre following arteriovenous access creation at another hospital.
The access had two venous outflow pathways, through the cephalic and basilic veins, which had developed to markedly different degrees.
The basilic vein was considerably better developed. In contrast, the cephalic vein had remained poorly matured along its distal and middle segments and demonstrated a high-grade, nearly filiform stenosis in its distal portion.
The cephalic vein was practically impossible to cannulate for haemodialysis. This was the principal reason for referral to our centre.
From a surgical perspective, superficialization or transposition of the better-developed basilic vein represented a feasible option for establishing a usable cannulation segment.
However, given the patient's advanced age and the additional procedural burden, we first explored whether the existing cephalic pathway could be improved sufficiently through an endovascular intervention.
Our primary objective was not simply to achieve a satisfactory angiographic result, but to establish a functional cannulation segment while preserving future treatment options.
Endovascular treatment
We decided to treat the stenotic cephalic outflow using a combination of mechanical vessel preparation and subsequent drug-coated balloon angioplasty.
Vessel preparation
The intervention began with FLEX Vessel Prep.
Several passes were performed through the stenotic segment, with the device rotated by approximately 90° between passes to address different aspects of the vessel circumference.
A control angiogram was obtained immediately after vessel preparation.
Interestingly, a marked improvement in the angiographic appearance was already evident at this stage, before subsequent balloon angioplasty.
DCB angioplasty
In the second step, we performed angioplasty using a paclitaxel-coated Aperto DCB (Cardionovum).
The final angiogram demonstrated a very satisfactory immediate morphological result.
Importantly, the basilic outflow was deliberately preserved, without ligation or embolization, maintaining an additional option for future surgical revision.
Technical details
Access: Distal retrograde access in the region of the distal cannulation aneurysm.
Lesion: High-grade to nearly filiform stenosis of the distal cephalic vein, associated with reduced maturation along its distal and middle course.
Vessel preparation: FLEX Vessel Prep, passes in four clock-face positions (12, 3, 6 and 9 o'clock), each a quarter turn apart, covering the entire circumference (360°)
Balloon angioplasty: Paclitaxel-coated Aperto DCB (Cardionovum) 6 × 60 mm
Basilic outflow: Preserved without ligation or embolization.
Access flow: Separate flow measurements for the two venous outflow pathways were not available; therefore, no quantitative flow values are reported.
Angiographic course
The three sequential angiograms document the treatment stages:
Before treatment → After FLEX Vessel Prep → After DCB angioplasty
The intermediate angiogram is particularly noteworthy, demonstrating substantial improvement immediately following vessel preparation, before DCB treatment.
This observation is interesting from a technical perspective, although the images alone cannot establish the mechanism of improvement or predict long-term clinical outcomes.
Clinical outcome
The cephalic vein, which had been practically impossible to cannulate before treatment, was successfully cannulated for haemodialysis the very next day.
This represented the most important immediate clinical result.
The intervention had achieved its primary objective: the existing access could be used through the cephalic pathway without requiring immediate superficialization or transposition of the basilic vein.
The basilic outflow remained intact as a potential option should further surgical revision become necessary.
Whether the improved cephalic pathway will provide reliable long-term access remains to be established through clinical follow-up.
Discussion
Individualized treatment rather than a standard solution
Chronological age alone should never determine whether a patient undergoes surgical access revision.
Nevertheless, the expected benefit of an intervention must be balanced against procedural burden, recovery, anticipated access use and the patient's individual circumstances.
In this case, basilic vein transposition was technically feasible and remained a reasonable surgical option.
However, the endovascular approach offered an opportunity to establish a usable cephalic cannulation segment without immediately exposing the patient to another operation.
Preserving the basilic outflow was an important part of this strategy, as it maintained an alternative pathway for possible future access revision.
What is the role of vessel preparation?
The substantial angiographic improvement observed immediately after FLEX Vessel Prep was one of the most interesting aspects of this intervention.
It raises the question of whether mechanical vessel preparation may facilitate treatment of selected dialysis access stenoses.
The sequential imaging allows the immediate angiographic response after vessel preparation to be distinguished from the final appearance following DCB angioplasty.
However, this single case cannot demonstrate that vessel preparation improves long-term patency or reduces the need for reintervention.
Similarly, the additional clinical benefit of the drug coating cannot be established from the immediate treatment result.
Longer follow-up and comparative clinical studies are required to answer these questions.
Function before morphology
A satisfactory angiographic result is encouraging, but it is not the ultimate objective of dialysis access treatment.
The clinically relevant question is whether the access can be used safely and reliably for haemodialysis.
In this patient, the transition from a practically non-cannulatable cephalic vein to successful cannulation on the following day was the most meaningful immediate outcome.
Nevertheless, one successful dialysis session does not establish sustained cannulation reliability or long-term access patency.
Further follow-up will be important to assess whether the cephalic pathway remains functional and whether additional endovascular or surgical treatment becomes necessary.
Conclusion
In this patient over 80 years of age, mechanical vessel preparation followed by DCB angioplasty enabled successful cannulation of a previously practically non-cannulatable cephalic vein on the following day.
The immediate angiographic improvement after FLEX Vessel Prep was particularly noteworthy.
At the same time, the basilic outflow was preserved, and a more extensive surgical procedure could be avoided for the time being.
Not every technically feasible operation is necessarily the best first step. The goal is to identify the most appropriate strategy for the individual patient.
Your experience?
How do you approach elderly patients with a well-developed basilic vein when transposition would require an additional operation?
And what has been your experience with mechanical vessel preparation before DCB angioplasty in dialysis access stenoses?
I look forward to your comments and clinical perspectives, either through the contact form or on LinkedIn.
Clinical case report. The findings describe the immediate outcome of an individual patient and do not establish comparative treatment superiority or long-term device effectiveness.
Conflicts of interest: The author declares no conflicts of interest.