When complex intra-stent occlusion demands outside-the-box thinking

A 78-year-old haemodialysis patient presented with left upper limb swelling and loss of AVF thrill after multiple prior interventions on the left subclavian vein.

Imaging revealed complete intra-stent occlusion, posing a critical challenge for access preservation.

What would be your next step?

Bruno Gargiulo

Vascular Surgery Unit University of Siena, Italy

Edoardo Pasqui

Vascular Surgery Unit University of Siena, Italy

Giuseppe Galzerano

Vascular Surgery Unit University of Siena, Italy

Gianmarco de Donato

University of Siena, Italy

Part I - Case presentation

Our patient was a 78-year-old man with end-stage renal disease under haemodialytic regimen with a history of prostatic cancer and myocardial infarction

03/2023: Proximal arterio-venous fistula creation (brachio-cephalic)
01/2024: PTA of subclavian vein stenosis (1)
08/2024: Stenting of severe subclavian vein re-stenosis (2)

1. Angioplasty of subclavian vein stenosis

2. Stenting of subclavian vein re-stenosis

The patient presented at the end of July 2025 with oedema and swelling of the left upper limb in the absence of AVF thrill.

Vascular duplex ultrasound revealed a complete occlusion of the left subclavian vein stent.