1. Very powerful finger occlusion and retrograde injection.

2. Was the brachial/axillary artery "occlusion" migrated thrombus or true narrowing/occlusion?

Why would you do a reflux image with thrombectomy? I always prefer to place a catheter in the brachial artery to get a forward flow image and avoid any thrombus migration into the artery.

I agree with Dr. Vachharajani. I try to never reflux with a thrombectomy. Sometimes, I will occlude at the arterial anastomosis if the access is high-flow to fully visualize the arterial system (this is after I placed a diagnostic catheter in the inflow artery or more proximal).

The first image is slightly confusing given the single frame and overlying vessels...not sure if is a high-takeoff Radial Artery or not, which indeed would be less-advantageous than a solid Brachial Artery.

As far as the reflux, it can be done as long as it is a hand injection and VERY SLOWLY, provided there is at least a small amount of restoration of flow. While there is still a chance of embolisation, I have even seen a deflated fogarty push clot into the artery during advancement.

Always surprised to see a upper arm graft in a young patient ...

Dr Vacharajani, your point is well taken. I do try to use catheter for arterial side but I am not committed enough to do it in every single patient. In someone like her where I may struggle with trying to make the wire go higher up and waste the crucial time in declot, I start with a very gentle reflux to rule out clots and then do the proper reflux.

In this case as Dr Hentschel pointed out, it was a powerful finger occlusion so there should be only the graft and one artery. Clearly in this I saw other vessles/venous flow. This made me concerned about possibility of another arterio-venous connection. With further imaging and mostly by ultrasound I found a deep fistula lower in arm that surgeon had created, it had not worked and he chose not to close it before creating the new graft. With low resistance flow available lower down in arm and the angulation of arterial anastomosis in this graft, the flow to graft was limited and likely contributing to reclotting. I talked to surgeon and had him close the fistula at elbow. I am hoping that it helps.

Again a proper documentation provided by surgeon about fistula and thorough review of history of accesses should avoid a situation like that in most cases, but my idea of presenting this was not finding something where I did everything perfectly, but to present a finding on angiogram that was important and I overlooked the first time.