'Piercing the Ring': Percutaneous Needle-Assisted Technique for Unyielding Arteriovenous Fistula Venous Stenosis

The study aims to describe a novel ultrasound-guided needle fenestration technique as a bailout strategy for balloon-refractory venous stenoses in arteriovenous fistulae (AVFs).

A 53-year-old man on maintenance hemodialysis presented with a dysfunctional brachiocephalic AVF. Following maximal angioplasty with standard, high-pressure, and ultra-high-pressure (UHP) balloons, a focal residual waist persisted despite edge-positioned UHP inflation and parallel wire-assisted dilation. Ultrasound revealed a discrete, circumferential fibrotic ring at the lesion site. Under real-time ultrasound guidance, percutaneous fenestration of the fibrotic ring was performed using an 18G needle, confined to the perivascular tissue. Subsequent angioplasty with the same UHP balloon resulted in complete waist effacement at 26 atm with restoration of flow.

No pseudoaneurysm, dissection, or extravasation was observed on follow-up imaging at 5 days, 1 month, and 6 months. The AVF remained functional until transplant. This technique was subsequently applied in other resistant lesions without any complications.

Ultrasound-guided needle fenestration is a safe, reproducible bailout option for discrete AVF stenoses. By disrupting the fibrotic ring, the lesion becomes more compliant, permitting successful dilation at lower pressures. This technique should be reserved for cases with sonographic identification of a periadventitial fibrotic ring and highly resistant lesions where maximal balloon-based escalation has failed.Clinical ImpactRecurrence following angioplasty in an AVF circuit is often due to incomplete obliteration of a residual stenosis following standard angioplasty that leads to increased morbidity and healthcare costs. Whilst high pressure, ultra high pressure and cutting balloons have considerably improved the outcomes of angioplasty, rarely there are resistant cases not amenable to these techniques. In this setting, the authors describe a simple, reproducible, cost effective technique to help open residual stenosis during angioplasty by making ultrasound guided needle fenestrations to the fibrotic ring at the stenosis.