Retrograde Stent Graft Placement for Chronic Total Occlusion of the Venous Anastomosis in a Forearm Loop Arteriovenous Graft: A Case Report.

Chronic total occlusion (CTO) at the venous anastomosis of an arteriovenous graft (AVG) remains difficult to treat endovascularly, particularly when an antegrade approach via the graft is unsuccessful. We report the case of a 90-year-old woman receiving maintenance hemodialysis through a left forearm loop AVG who developed progressive access dysfunction due to a CTO extending from the venous anastomosis to the downstream basilic vein. Because antegrade recanalization had failed and surgical revision was considered less desirable given her advanced age, frailty, and fragile skin condition, an alternative endovascular strategy was selected. Preprocedural ultrasound confirmed a downstream basilic vein segment suitable for retrograde puncture. Under ultrasound guidance, the downstream outflow vein was punctured, and a 6-Fr sheath was inserted retrogradely. After successful retrograde wire crossing of the occluded segment, cautious predilation was performed with a 4 × 40 mm balloon, followed by retrograde deployment of a 6 × 100 mm stent graft with overlap into the graft. Technical success was achieved without complications. The procedure was completed on an outpatient basis in 58 minutes. Postprocedural duplex ultrasound showed improved access hemodynamics, and the AVG remained functional without restenosis or reintervention at approximately six months of follow-up. This case suggests that retrograde stent graft placement via the downstream outflow vein may be a feasible salvage option in carefully selected patients with venous anastomotic CTO of an AVG when an antegrade approach is unsuccessful.