PTA induced arterial rupture is a rare but serious complication in percutaneous coronary intervention and has also been reported for femoral, popliteal, iliac and renal artery interventions (Yeo et al. 2008). However in AVFs, whilst venous rupture is well-documented, there is a paucity of literature on arterial rupture.

As per standard practice, a retrograde transvenous puncture was used. Whilst some studies have discussed the putative advantages of an arterial approach in treating multiple downstream lesions with a single sheath, we considered the retrograde transvenous approach as the most appropriate in our scenario as only a single juxta-anastomotic lesion had been identified and good access and control had been established from the initial puncture site (Le et al. 2015). This also avoided potential complications of arterial puncture including arterial occlusion, vasospasm, further rupture and difficulties with closure and haemostasis.

There are few specifically designed or licensed stents for use in AVFs and a wide variety of stent types have been tried off-label. To the best of the authors’ knowledge, this is the first case report describing the use of a BeGraft coronary stent-graft, a balloon-expandable expanded-polytetrafluoroethylene (ePTFE) covered Cobalt-Chromium stent-graft, to manage juxta-anastomotic arterial rupture and pseudoaneurysm complicating fistuloplasty for a radio-cephalic AVF stenosis.

Whilst BeGraft is commonly used in coronary intervention, a small number of studies have reported application of a BeGraft coronary stent-graft within a comparable non-coronary context such as in traumatic or iatrogenic injury to the anterior tibial artery and other small vessels including the renal, gluteal and ascending cervical arteries (Brunoro et al. 2019; Ruffino et al. 2020).

Due to the small calibre of the radial artery and the short segment requiring exclusion, a low-profile covered stent was required to manage this. Stent-grafts traditionally used for peripheral interventions such as the Viabahn (WL Gore & Associates) or Fluency Plus (Bard), both self-expanding ePTFE covered Nitinol stent-grafts, would not have met these requirements due to their larger profiles. Furthermore, balloon-expandable stent-grafts allow for more precise positioning as they do not require stepwise deployment, making the BeGraft coronary stent-graft the most suitable option for this application.

Sufficient segments of proximal and distal landing zones were identified for stent-graft placement to adequately exclude the pseudoaneurysm without crossing the anastomosis. Had an adequate distal arterial landing zone not been present, it would have been feasible to cross the anastomosis with the stent-graft as we had demonstrated adequate retrograde flow from the ulnar artery via the intact palmar arch. This alternative placement would have been suboptimal as the angulation of the anastomosis would have increased the risk of stent fatigue. Both explant and in silico data demonstrate that pulsatile fatigue-related damage of stent-grafts concentrate in areas of severe angulation and bending (Dalbosco et al. 2020; Zarins et al. 2004).

Irrespective of the approach used to treat AVF arterial rupture and pseudoaneurysm, whether balloon tamponade or stent-graft deployment is used or the positioning of the stent-graft, it is vital to assess for adequate retrograde blood flow via the palmar arch from the ulnar artery. This can be clinically proven by neurovascular assessment, the Barbeau test and sonographically by ultrasound of the distal vasculature. If necessary, prolonged tamponade in arterial rupture and stent-grafting across the anastomosis can be safe with confirmation of the above.

Despite the high technical success rate demonstrated by stent-grafts in both AVF vessel rupture and pseudoaneurysms, there are a few limitations. Covered stent-grafts are not designed for repeat cannulation which means once deployed, the area must be marked to avoid cannulation over that site as in our patient.

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