Direct stent puncture-assisted recanalization for occluded central venous stent graft

Central venous occlusive disease (CVOD) is a common complication in hemodialysis patients, often necessitating endovascular interventions such as angioplasty and stenting. However, stent occlusion remains a significant challenge, with conventional recanalization techniques frequently failing. This case report describes the successful application of a direct stent puncture (DSP)-assisted bidirectional approach to revascularize a refractory occlusion of a central venous stent graft in a 70-year-old hemodialysis patient. Initial attempts via femoral and fistula access failed to cross the occluded innominate and subclavian vein segments. Under multiplanar fluoroscopic guidance, DSP was performed to puncture the mid-portion of the stent, followed by guidewire advancement with sheath support. A through-and-through femoral-to-fistula circuit was established using wire snaring and externalization, enabling balloon angioplasty and additional stent deployment. The procedure achieved immediate technical success with resolution of symptoms. This case highlights DSP as a viable salvage technique for complex venous stent occlusions, particularly when combined with complementary endovascular strategies. Key advantages include precise puncture localization and bidirectional force application, which may improve recanalization rates in challenging scenarios. Further studies are warranted to validate its efficacy and safety in larger cohorts.