Treatment of Severe Outflow Stenosis Leading to Steal Syndrome

Introduction: 67-year-old F with ESRD on dialysis via a left brachiobasilic AV fistula created several years ago with multiple previous interventions was referred to interventional nephrology for venous pressures of 300 mmHg on 400 ml/min pump flow. Case Description: Access was obtained and angiogram showed an extremely hypoplastic basilic vein draining to the brachial system via a perforator vein. Balloon angioplasty was performed incrementally with 4x40, 6x40, and 8x40 compliant Powerflex balloons. Due to the high recurrence likelihood and the severe stenosis, an 8x60 drug-eluting Lutonix balloon was deployed. Patient had significant discomfort and arm swelling upon balloon deflation, with angiogram showing extravasation. Immediate balloon occlusion was done, but due to continued swelling and extravasation, an 8x100 Viabahn stent was deployed. Post-procedure, fistula had excellent flow(Fig. 1). Later, patient developed left-hand numbness and pain during dialysis concerning for steal syndrome. Vascular surgery performed angiogram showing significant stenosis in the axillary/brachial artery junction with subsequent angioplasty and symptom improvement(Fig. 2). Discussion: Extravasation can occur in dialysis access interventions with covered stents used as bailout procedures. In this case, despite successful angioplasty of the significantly diseased segment of the basilic vein, there was enough flow resistance to prevent steal syndrome. The stent deployment increased flow, reducing resistance and unmasked arterial stenosis in the upper brachial artery leading to successful treatment and resolution of steal syndrome.