[Cephalic arch stenosis. Case report and literary review]

Dysfunctional AVF represents one of the leading causes of morbidity in the hemodialysis population, with venous stenosis-related dysfunction being the most common underlying problem. Cephalic arch is a well-known site for the development of stenosis, especially in patients with brachiocephalic fistulas. The pathophysiology of cephalic arch stenosis (CAS) is still being investigated and various contributing factors have been suggested. The treatment options for CAS are many and include angioplasty, endovascular stent insertion, access flow reduction and surgical interventions, but none of the current modalities are ideal. Therefore, the treatment of CAS is difficult, as the stenosis in this area tends to recur leading to the need for repeat angioplasty, stents or surgical revision. A 57-year-old woman undergoing hemodialysis (HD) through a right brachiocephalic arteriovenous fistula was found to have high venous pressure during HD and prolonged bleeding after HD. Clinical examination revealed a hyperpulsatile fistula suggestive of outflow obstruction. Doppler ultrasound examination showed cephalic vein thrombosis, severe outflow stenosis and juxta-anastomotic area. A 10 x 40 mm stent (Cordis Smart stent) was positioned appropriately in the cephalic arch and deployed, the stenotic lesion in juxta-anastomotic area was dilated with angioplasty balloon with improvement in flow. After 14 months, the fistula is still working perfectly with adequate flow.