Case Interpretation| Application of Tri-Wedge™ in Juxta-anastomotic Stenosis(JAS) of AVF

In the previous issue of case sharing, we presented a complex coronary intervention case, in which the Alveo HP Φ0.75 balloon, independently developed by BrosMed Medical, demonstrated excellent performance in crossing the lesion and dilation, showcasing exquisite craftsmanship of innovation.

Today, we bring you a new case. Let’s take a look at what other innovative product will help clinical practitioners in this case……

Case information

Patient Information: Male, 62 years old, 68 kg.

Visiting time: June 9, 2020.

Chief complaint: Hemodialysis for 3 years, and arteriovenous fistula (AVF) dysfunction found for 1 week.

History of present illness: The patient had failed left forearm AVF formation 3 years ago, and subsequently underwent a right upper extremity AVF formation. After the maturation of AVF in the right upper extremity, maintenance hemodialysis treatment was initiated. One week ago, the dialysis nurse reported an “arterial pressure alarm”, and outpatient ultrasound examination revealed localized stenosis in the AVF.

Past medical history: Hypertension, and type 2 diabetes mellitus.

Admission examination

Physical examination: No obvious abnormalities were found in general physical examination. A surgical scar was seen on the right forearm, and high-pitched vascular bruit could be heard at the juxta-anastomotic site of the AVF. Palpation revealed tremors and a weak pulsation. No apparent aneurysmal dilation was found in the AVF region of the right upper extremity.

Laboratory tests: Hb 117g/L, Alb 40.0g/L, Cr 1205 μmol/L, Ca 2.08 mmol/L, P 1.39 mmol/L, K 4.65 mmol/L, CO2 23.5 mmol/L.

Ultrasound examination:

Diagnostic result:

▪ Stenosis in autologous AVF and maintenance hemodialysis

▪ Stenosis at the juxta-anastomotic site measured 1.2 mm, intimal hyperplasia, and estimated Qa 250 mL/min

Surgical procedure

01 Balloon dilatation

The Tri-Wedge™ scoring balloon could dilate the narrowed area by passing through the lesion, exerting pressure up to 12 ATM, and then withdrawing.

02 Ultrasound imaging

The scoring balloon catheter with three triangular metallic wires was well-defined, allowing for accurate positioning under ultrasound.

The balloon catheter was well-defined

03 Postoperative blood flow monitoring

▪ Estimated Qa 824 mL/min immediately after operation

▪ Estimated Qa 981 mL/min 24h after operation ▪ Estimated Qa 920 mL/min 1 month after operation

▪ Estimated Qa 920 mL/min 1 month after operation

Postoperative summary

Case characteristics:

The patient underwent autologous AVF hemodialysis. During the process, inadequate blood flow was observed. Physical examination revealed a high-pitched vascular bruit and weak palpable tremors.

Assessment of preoperative points:

The physical examination and imaging evaluation of the AVF were performed to determine the site of lesion and estimate the brachial artery blood flow.

Surgical points:

The appropriate vascular access route and balloon catheter model were selected. The balloon was accurately located to the target lesion under imaging guidance, and then gradually inflated by pressure, followed by the withdrawal of balloon catheter. Finally, the surgical outcome was assessed.

Device use points:

The scoring balloon catheter, featured by three triangular metallic wires, is designed for accurate positioning under ultrasound guidance. The balloon is gradually inflated by pressure, enabling the scoring wires to exert the collected pressure on the vessel wall, which improves the success rate of the operation while reducing the expansion pressure.