Cephalic arch stenosis: mechanisms and management strategies

Cephalic arch is a frequent site for the development of stenosis in patients with brachiocephalic fistulae. This is in part owing to the anatomic constraints of the cephalic arch region and the exertion of hemodynamic forces at this site caused by the creation of a brachiocephalic fistula. Multiple interventions have been used to correct stenosis and subsequent fistula dysfunction. These include percutaneous balloon angioplasty using conventional and cutting balloons, endovascular stent insertion, and surgical interventions. It is important to emphasize that the stenosis in this region frequently recurs, is more resistant to angioplasty, and shows a higher rate of rupture during the percutaneous balloon angioplasty procedure compared with peripheral lesions at other sites. Because hemodynamic forces have been postulated to be one of the culprits for the development of stenosis, a new technique of flow reduction has been introduced to combat this problem. This article discusses the etiology, pathophysiology, and current management of cephalic arch stenosis.