Recurrent cephalic arch stent graft twisting salvaged by bare metal stents reinforcement

Cephalic arch stenosis (CAS) is a common cause of arteriovenous fistula (AVF) dysfunction. Angioplasty, with or without bare-metal stent, is associated with a high risk of early restenosis. The use of a stent graft at the cephalic arch is gaining popularity, as it improves patency rates and decreases the number of reinterventions. This case report describes a 65-year-old woman with end-stage renal failure who had a right brachiocephalic AVF created for haemodialysis. She suffered from cephalic arch stenosis, which repeatedly recurred despite multiple angioplasties. A stent graft was deployed but was complicated by twisting, leading to recurrent dysfunction. The twist was finally resolved with additional venous bare stents to provide mechanical support. This case highlights the potential complication of stent graft twisting and illustrates an endovascular solution to that. The underlying reasons for the twist are also postulated, which may provide insights for future treatment planning in CAS.