I have seen a lot of "clotted"accesses that were actually not clotted at all, or not completely so. A fistula may be dilated and full of laminated clot, but with a channel running through it - since it may be functionally unusable, it is "clotted", even though blood may be running through it. This is sometimes the case when aneurysmal fistulas are declotted by virtue of placing covered stents through the thrombus - difficult to cannulate, and the dead-zone clot around the stent frequently gets seeded, and abscessed. Other fistulas may be dilated and clotted through most of their length, but kept patent at the lower end due to an early branch - the arterial pressure wave makes the fistula painful, and the early branch creates uncomfortable venous hypertension in the forearm (typically) . I always look for patent arterialized branches off abandoned "clotted" fistulas. Treating these leads to gratifying results. Send the patient to a more experienced access surgeon

I agree with Dr. Webb

If I were the patient, I wouldn't let anyone create another access in my other arm until I had the painful one dealt with. Simplest thing to do is to just excise the thing, ligating the stump reasonably close to the arteriovenous anastomosis.

Dr. Ladneheim's response is typically what is practiced here. Stent grafts/covered stents for this type of presentation only play a role in our practice when the chronic occlusion is minimal length (3-4cm), if the skin over the access site includes enough scar or fat to prevent stent related complications, and there are otherwise no better surgical options.