Retroclavicular termination of the cephalic vein mimicking cephalic arch stenosis: A rare cause of recurrent haemodialysis access dysfunction successfully treated by cephalic vein transposition

Cephalic arch stenosis is a well-recognised cause of brachiocephalic arteriovenous fistula (AVF) dysfunction, whereas congenital anomalies of cephalic vein termination are rare and may produce atypical mechanisms of dialysis access failure. We report a 60-year-old man with end-stage renal disease and a left brachiocephalic AVF who developed recurrent access dysfunction despite repeated technically successful endovascular interventions. Duplex ultrasound demonstrated a haemodynamically significant outflow stenosis. Fistulography revealed an aberrant cephalic vein coursing far medially and entering the subclavian vein from a caudal direction. Three-dimensional angiographic imaging and computed tomography demonstrated focal compression of the terminal cephalic vein between the clavicle and first rib, while the central venous system remained patent. Repeated balloon angioplasty, including drug-coated balloon angioplasty, produced only temporary improvement because of persistent extrinsic compression. Stent implantation was avoided because of the anticipated risk of mechanical compression, deformation, fracture, and poor long-term durability. Definitive treatment consisted of surgical transposition of the cephalic vein to the axillary vein, resulting in immediate haemodynamic improvement and restoration of satisfactory dialysis access function. Aberrant retroclavicular termination of the cephalic vein into the subclavian vein should be considered in patients with recurrent cephalic outflow stenosis, particularly when endovascular treatment repeatedly fails despite a patent central venous system. To our knowledge, this is the first reported case of recurrent haemodialysis access dysfunction caused by this anatomical variant and successfully treated by surgical cephalic vein transposition.