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Under ultrasound guidance, a 21-gauge micropuncture needle was advanced directly into the rightcommon femoral artery. A 0.018 inch wire was advanced through the needle. The needle was exchanged for 5 French dilator sheath combination. The inner dilator wire removed.
Subsequent, a 0.035 inch exchange length glide wire was advanced into the aorta. The outer sheath was exchanged for a 5 French hemostatic sheath.
A 5 French diagnostic catheter was advanced over the wire and positioned in the thoracic aorta.

Thoracic aortogram was performed. Subsequently, the catheter was exchanged for a 5 French Kampe catheter which was selectively into theleft subclavian artery. Selective subclavian artery and axillary artery angiogram was performed.

The catheter was exchanged for a multi-sidehole straight catheter which was subsequently advanced intothe brachial artery. Selective angiogram of the brachial artery was performed in a stepwise fashion to the antecubital fossa. Subsequently, stepwise fashion arteriogram was performed in the radial and ulnar arteries to the wrist.

The catheter was exchanged for a 2.5 mm x 40 mm angioplasty balloon over a 0.014 inch wire which waspositioned in the stenosis within the radial artery. Angioplasty was performed.
Subsequent, the balloon was positioned into the fistula anastomosis. Angioplasty was performed. Finally,the balloon was positioned in the radial vein. Angioplasty was performed. The balloon and wire wereremoved.
Post angioplasty angiogram was performed.
Selective right common femoral artery angiogram was performed. Angio-Seal closure device wasdeployed at the puncture site following removal of the hemostatic sheath. Hemostasis was obtained.
There are no procedural or immediate postprocedural complications.

Findings:
Initial evaluation demonstrates a patent thoracic arch. The subclavian artery, axillary artery and brachial arteries are widely patent. The radial and ulnar arteries were identified. There is a short segment hemodynamically significant stenosis of greater than 80% in the radial artery proximal to the radial artery fistula anastomosis. In addition, there is diffuse stenosis at the fistula anastomosis as well as in the proximal limb of the fistula. The graft following angioplasty with a 2.5 mm x 40 mm balloon, there is considerable improvement in flow in the fistula. However, there is a short segment critical stenosis in the venous outflow which could not be crossed with the balloon. The patient will return for fistula access with subsequent angioplasty directed toward the arterial anastomosis.
The patient tolerated conscious sedation well.
The right common femoral artery is widely patent. Angio-Seal closure device was deployed at thepuncture site with hemostasis achieved.

Impression:
Initial evaluation demonstrates widely patent thoracic aorta. Normal appearance of the subclavian artery, axillary artery and brachial artery.
There is a hemodynamically significant stenosis in the radial artery proximal to the fistula anastomosis. In addition, there is long segment stenosis in the fistula anastomosis as well as in the venous outflow.
Successful angioplasty was performed in the radial artery as well as in the fistula anastomosis. Therewas a critical stenosis in the venous outflow which could not be crossed with the balloon. The patient will return for angioplasty of the remaining stenosis in the venous outflow.
The patient tolerated conscious sedation well
The right common femoral artery is widely patent. Angio-Seal closure device was successfully deployed.