Balloon-assisted cusp avulsion technique for subclavian venous valve stenosis in a hemodialysis patient: A case report with IVUS confirmation

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BACKGROUND: Subclavian venous valve stenosis is a rare but significant cause of upper extremity venous hypertension in hemodialysis patients. When standard endovascular treatments are not feasible, alternative techniques may be required. CASE PRESENTATION: A man in his 60s with end-stage renal disease on maintenance hemodialysis for 19 years, with a right forearm prosthetic arteriovenous graft (AVG), presented with right upper extremity edema and dialysis dysfunction due to subclavian vein occlusion. Intravascular ultrasound (IVUS) revealed fibrotic valve leaflets at the occlusion site. An 8 mm balloon was pulled through the lesion under IVUS and fluoroscopic guidance, resulting in partial cusp rupture. A second 12 mm balloon and a kissing balloon technique with a cutting balloon achieved complete valve disruption. The pressure gradient dropped from 20 to 0 mmHg, and dialysis resumed without complications. CONCLUSIONS: This is the first reported case of IVUS-guided balloon-assisted cusp avulsion (BACA) technique for treating fibrotic venous valve stenosis. This approach may offer a viable stentless option when conventional stenting is not feasible due to anatomical or technical limitations.

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