difficult dialysis access creation- chest loop

This is a dialysis patient with exhausted bilateral arm's venous property. Due to the need of long term dialysis, I have created a anterior chest loop graft for her some 6 years ago. And fortunately, the anterior chest dialysis graft lasted functional for over 6 years. Several weeks ago, because of the degenration of the graft, low flow with frequent thrombosis was noted.
My stratagy is : insert a cuffed tunneled catheter via the right internal jugular vein for dialysis and perform a anterior chest dialysis graft redo procedure. I have implanted a new graft and do the anastomosis of either end of the graft to the original graft inlet and outelt stumps.

I think, with meticulous work and proper clinical judgment, we still can perform dialysis graft for long term usage on those patients whose bilateral arm are not suitable for graft creation. The anterior chest loop graft is one of the form which can/should be considered.

Method to treat dialysis graft outelt stricture

Outlet stricture is the most common problem of dialysis graft. If not treated properly, it may lead to dialysis graft thrombosis. How can we deal with dialysis graft outlet stenosis?
Traditionally, surgeons can do an venous outlet revision, either by patch angioplasty or jump graft revision, to address the problem of graft outlet stricture. its a rather staightforward way to treat the lesion. However, surgical revision needs surgical exploration of the vessel and is more invasive and time consuming. (compare to recently endovascular method)
Nowadays we can treat the lesions using P.T.A.. That is to say, we may dilate the stricture using angioplasty balloon percutaneously. However, rocoil or recurrence of the stenosis may need repeated procedures.
And if the lesion is refractory to angioplasty alone or it recured early, we may put in stents to prevent the recoil of the lesion. In my experience, we should put in covered stents in stead of bare metal stents to treat the dialsis graft outelt lesions. Because it seems that the bare stents do have the problem of in-stent stenosis in short time.

The picture showes here depict a typical graft outlet lesion, which is refractory to P.T.A, successfully treated using a covered stent uneventfully(Fluency, Bard)

P.T.A.

P.T.A. stands for "percutaneous transluminal angioplasty". It is a less invasive percedure , compared to the traditional surgical revision, to treat vessel stenosis or occlusion.
"Percutaneous" means that the procedure is start with sticking a needle into the target vessel through the skin in stead of cutting a big wound to exposure the vessel. Once the access to the vessel was created, a working sheath was inserted into the vessel, just like doing a "i.v." injection, to secure the access. We can then insert some kind of catheter, guidewire and balloons via the sheath to attack the lesions (stenosis or occlusion).
"transluminal angioplasty" means that the procedure is comprised of dilatation of the stenotic vessel segments (angioplasty) using angioplasty balloons instead of repair the lesions using traditional "cut and sew" methods.
In short, when doing P.T.A. , we insert a balloon over a guidewire into the vessel percutaneously and send the balloon right to the target lesion (where the vessel is stenotic). And then we inflat the balloon to dilate the vessel upto the diameter we disire to increase the blood flow. At the endo of the procedure, we take out the catheters and balloons. Through P.T.A we can treat vessels with only with punture wounds and we don't have to cut the vessels anymore.

We can apply this kind of P.T.A technique to treat the vessel problems , including arteries and veins, all over our body.