Cross-elbow stent placement for refractory arteriovenous fistula stenosis and chronic total occlusion in hemodialysis patients: a single-center retrospective cohort of 42 cases

Cross-elbow stent placement in hemodialysis arteriovenous fistulas (AVFs) has been avoided due to risks of fracture, kinking, deformation, migration, and infection. However, elbow lesions may be refractory to angioplasty and progress to chronic total occlusion (CTO). We evaluated the safety, feasibility, and patency of cross-elbow stenting for AVF salvage. Consecutive adult hemodialysis patients who received cross-elbow stents for clinically significant AVF stenosis or CTO (September 2021 – March 2026) at a single center were retrospectively analyzed. Primary outcomes were target lesion primary patency (TLPP), access circuit primary patency (ACPP), access circuit secondary patency, and access circuit assisted primary patency, estimated by Kaplan–Meier. Technical and clinical success and complications were recorded. Forty-two patients were included; 45.2% had CTO and 57.1% had prior PTA. Eluvia-based stents were used in 83.3%. Technical and clinical success were both 100%. Mean access flow increased from 407 ± 267 to 839 ± 188 mL/min. TLPP at 3, 6, 12, and 24 months was 90.1%, 84.4%, 76.9%, and 76.9%, respectively. No stent fracture, migration, kinking, or infection occurred. Cross-elbow stenting was technically feasible and provided favorable short- to mid-term patency without device-related complications, supporting its use as a salvage option for selected refractory AVF lesions and CTOs. What is known: Stents crossing the elbow joint have historically been avoided because repetitive elbow motion may cause fracture, kinking, deformation, or migration; evidence for elbow-segment AVF salvage remains limited. What this study adds: In 42 selected patients, cross-elbow stenting achieved 100% technical and clinical success, 76.9% TLPP at 12 months, and no observed stent fracture, migration, clinically relevant kinking, or infection. Potential impact: Flexible stents, including drug-eluting stents, may be considered as a salvage option for selected refractory elbow-segment AVF stenoses and CTOs, while prospective comparative studies remain necessary. People receiving hemodialysis need a reliable arteriovenous fistula for treatment. Narrowing or blockage near the elbow can be difficult to treat, and clinicians have often avoided placing stents across the elbow because repeated bending might damage the stent. We reviewed 42 patients treated with a stent crossing the elbow. All procedures restored fistula function, blood flow improved, and about three-quarters of treated sites remained free from repeat treatment at 12 months. No stent fracture, migration, clinically important kinking, or infection was observed. These findings suggest that a flexible stent may be a useful rescue treatment for selected difficult fistula lesions, although larger prospective studies are needed.