75 y/o Hispanic male with ESRD on dialysis  with a LUA brachial straight graft from 2010. He had an 8x50 Flared Flair stent placed at the venous anastomosis  in 2011, had done well until 2016. He presented to our outpatient vascular access center with elevated venous pressures and prolonged bleeding. Six weeks prior he presented with the same access issues and had in-stent stenosis that underwent PTA with good result. No other pertinent medical history.

On angiogram he was found to have severe  in-stent stenosis (fig. 1). PTA with a 9x4 Conquest was done with full effacement but a residual of greater than 50% was noted. A 9x50 Flared Flair was placed with 10mm overlap of the stents in the non flared section. The stent was deployed slowly but did not seem to flower well all the way back (fig. 2). A 9x4 Conquest was carefully placed to seat the stent, the stent migrated forward but was caught with the balloon (fig. 3). The stent on the balloon was pulled slightly back into the prior stent but could not be well overlapped or seated at that point as it was expanded (fig. 4). The balloon was removed and and a 10x100 Fluency stent was placed, as the Flared Flair stent continued to slowly migrate. The fluency was seated with a 10x4 Conquest and overlapped the original stent and most of the 9x50 Flared Flair stent with a space in between the two. (fig. 5). Final angiogram shows good flow (fig. 6).

Questions:

1) Should one avoid using a flared stent in a flared stent ?

2) Should one overlap more than the standard 10mm when stenting at the angle of the access (use a longer stent)?

3) Should I just snare/retrieve an unlanded stent ?

4) Should I have just pulled the stent/shaft out when I noticed the stent not flowering well (50% deployed at that point) (placed bareback) ?

Thanks