Intraluminal calcification as a potential cause of late arteriovenous graft failure in a patient with chronic kidney disease–mineral and bone disorder

Arteriovenous grafts (AVGs) are important vascular access options for maintenance hemodialysis. Late AVG failure is commonly attributed to venous anastomotic stenosis, thrombosis, infection, or pseudoaneurysm formation. In contrast, intraluminal calcification is rarely recognized as a direct cause of access dysfunction. We report a 78‑year‑old woman with end‑stage kidney disease secondary to obstructive nephropathy and a history of hypertension, but without diabetes mellitus (BMI 24.65 kg/m 2 ), who had undergone left forearm AVG implantation in October 2016. The graft had been used for maintenance hemodialysis for 9 years and 8 months (from October 2016 to April 2026). During follow‑up, she underwent eight endovascular interventions for recurrent graft thrombosis and insufficient access flow, with one non‑tunneled central venous catheter placement. She had Chronic kidney disease-mineral and bone disorder (CKD-MBD) and was receiving calcimimetic therapy. In April 2026, she was admitted because of recurrent insufficient dialysis blood flow and progressive cannulation difficulty, characterized by marked resistance during needle insertion and a gritty sensation, often requiring multiple attempts to access the lumen. Ultrasound showed hyperechoic stenotic lesions within the graft, suggesting calcified graft stenosis. Surgical exploration revealed extensive firm whitish material adherent to the inner wall of the original graft, occupying approximately 80% of the lumen as estimated by gross visual inspection of the resected specimen. The diseased graft segment was resected, and a new prosthetic graft was tunneled along a revised subcutaneous route and anastomosed to the original anastomotic site. Histopathological examination confirmed calcium salt deposition within fibrous collagenous tissue. One month after surgery, the reconstructed AVG was successfully used for hemodialysis. This case highlights intraluminal calcification as a potential structural cause of late AVG failure in patients with CKD‑MBD.