Figure 514

Outflow vein stenosis with stenting. A, Arteriography in this patient with a Brescia-Cimino fistula demonstrates stenosis of the outflow vein approximately 15 cm central to the fistula (arrow). B, Percutaneous transluminal angioplasty was performed in this patient; however, because of immediate elastic recoil, the lesion looks no different after angioplasty. C, Following stent placement (arrow), there is no residual stenosis, and good flow through the stent is apparent. Stents have proven controversial in access sites. Although they may improve patency in central vein stenoses (vide infra), in the periphery they may be a hindrance. Some patients develop vigorous fibrosis at the venous site of a stent. D, This photograph demonstrates what had occurred only 1 month after stent placement. Stents can be a problem when dealing with subsequent vascular access dysfunction. During thrombectomy, the tiny wires of a stent can puncture balloon catheters. When stent-ed segments restenose, it is impossible to perform open patch angioplasty over such segments, and it becomes necessary to jump to a different venous outflow site. It is not clear whether stents in or adjacent to dialysis grafts are cost effective in maintaining graft patency.

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