Moderate or severe vascular calcification is associated with an increased risk of restenosis and need for reinterventions after endovascular treatment of peripheral artery disease. Further, calcification, whether medial, chronic total occlusions with resistant or calcified caps, or calcific nodules, all increase the potential complexity of the intervention. Current calcium modification devices can be limited due to their ability to cross severely stenosed lesions or are associated with an increased risk of vessel damage and distal embolization. The Shockwave Javelin peripheral intravascular lithotripsy (IVL) catheter has no balloon but uses a single IVL emitter located immediately proximal to the tip of the catheter and is designed to modify and cross calcified high-grade stenoses, subtotal occlusions, and occluded vessels. The prospective, single-arm Mini S Feasibility and FORWARD PAD Investigational Device Exemption studies assessed the safety and effectiveness of the novel Javelin peripheral IVL catheter. One hundred ten subjects with angiographic evidence of moderate to severely calcified peripheral artery disease and Rutherford Category 2 to 5 were enrolled from March 2022 to February 2024. Scenarios well suited for the Javelin IVL catheter became evident in this early experience with the device and are described in detail with case examples. Written informed consent for the collection and publication of data was obtained prior to any study-specific requirements. The primary safety and effectiveness endpoints of the study both met prespecified performance goals: major adverse events (cardiovascular death, clinically driven target lesion revascularization, or unplanned target limb major amputation) at 30 days was 1.1%; technical success (core lab-adjudicated final residual stenosis of ≤50% without flow-limiting dissection) was 99.0%. The study cohort also had significant improvements in residual stenosis and a low rate of serious angiographic complications (1.0%) at final imaging. The Javelin catheter was found to be particularly useful in situations including severely stenosed lesions in smaller diameter infrapopliteal arteries where the fixed diameter due to an absence of a balloon allows for better crossing, calcified nodules, and chronic total occlusions where focal treatment at the tip of the catheter is important. Although the FORWARD PAD Investigational Device Exemption/Feasibility studies showed a favorable safety and efficacy profile, continued real-world assessment will be necessary to understand the long-term performance of the device and how the Javelin peripheral IVL catheter fits into the broader calcium modification algorithm.
Accurate cross-sectional imaging is essential for diagnosis, procedural planning, and postintervention surveillance in patients with peripheral artery disease (PAD). Conventional computed tomography angiography (CTA) is limited by calcium blooming, beam hardening, and reduced diagnostic accuracy in small and heavily calcified vessels. Photon-counting computed tomography angiography (PCCTA) represents a recent technological advancement with the potential to overcome these limitations. This review summarizes the technical principles of PCCTA and evaluates current evidence regarding its image quality, diagnostic performance, and clinical implications in PAD. A narrative review of peer-reviewed literature and scientific presentations was performed using MEDLINE, Scopus, and Google Scholar from database inception through October 22, 2025. Search terms included "photon-counting CT," "photon-counting computed tomography angiography," "peripheral artery disease," "below-the-knee angiography," and "ultra-high-resolution CT." Studies evaluating image quality, diagnostic accuracy, reconstruction techniques, and clinical applications of PCCTA in peripheral artery disease were included. PCCTA utilizes energy-resolving detectors that directly count and bin individual X-ray photons, enabling true spectral imaging, reduced electronic noise, and smaller detector pixel sizes. These features result in improved spatial resolution, higher contrast-to-noise and signal-to-noise ratios, and marked reduction of calcium blooming and beam-hardening artifacts. Multiple cadaveric, phantom, and in vivo studies demonstrate superior visualization of infrapopliteal vessels and stented arterial segments compared with energy-integrating and dual-energy CT systems. Reported sensitivity, specificity, and accuracy for PCCTA stenosis grading in PAD imaging reach approximately 96%, 97%, and 97%, respectively, incrementally exceeding those of conventional and dual-energy CT techniques, particularly in heavily calcified and below-the-knee vasculature. Optimization strategies, including sharp reconstruction kernels, high iterative reconstruction levels, and submillimeter slice thickness, further enhance diagnostic confidence. PCCTA also allows for substantial reductions in iodine contrast volume and radiation dose while maintaining diagnostic image quality. PCCTA represents a significant advancement in lower extremity arterial imaging for PAD. Improved visualization of small, calcified, and stented vessels enhances diagnostic accuracy, procedural planning, and postintervention surveillance. Although widespread adoption is currently limited by cost and scanner availability, emerging evidence suggests PCCTA may redefine cross-sectional imaging in PAD and improve patient-specific treatment strategies. However, further large-scale, prospective research is needed to establish the diagnostic benefits this modality in the clinical space.
Functional popliteal artery entrapment syndrome (FPAES) is a rare disorder that results from hypertrophy and overuse injury of calf muscles, which thereby compress neurovascular structures in the popliteal fossa. The majority of FPAES cases are found in young athletes who present with symptoms during exercise. Most commonly, FPAES is surgically treated with muscle debulking utilizing a posterior S-shaped incision, but wound healing and neuropathy remain problematic in this approach. Here, we present our case series of college athletes undergoing FPAES repair using a novel medial calf approach that avoids surgical incision across the joint space. This is a retrospective analysis of all FPAES repairs performed at our institution from 2016 to 2023. The popliteal fossa was entered by a 10- to 12-cm incision on the medial aspect of the calf. Exploration of the popliteal artery, vein, and neurovascular bundle was performed. Tenotomy of the soleus and tenotomy and debulking of the medial gastrocnemius were performed. We studied postoperative wound complications, pain, neurovascular symptoms during in-hospital and long-term follow-up periods, postoperative analgesia use, length of stay, pre- and postoperative ankle brachial indices (ABIs), and lower extremity arterial duplex. Twenty-four patients were included, 23 of whom underwent bilateral repair (47 limbs total). The mean age was 21.9 years (standard deviation, 7.7 years). Most patients were female (83.3%), and all patients reported exercise-induced lower extremity pain. Most patients had a reduction in preoperative ABI after exercise (mean preoperative resting ABI, 1.19; mean preoperative exercise ABI, 0.94). Lower extremity arterial duplex revealed a nearly two-fold increase in mean blood velocity among patients after exercise (mean velocity at rest, 65.8 cm/s; mean velocity during plantarflexion, 120.9 cm/s). Nine patients (36.2%) had prior operations related to exertional compartment syndrome in the lower extremities. The median length of stay was 1 day. Postoperative exercise ABI showed marked improvement compared with preoperative values in all athletes. Twenty-one of 24 patients (87.5%) resumed competitive sports without restriction at a median of 59 days after surgery. Of the three patients who did not return to competition, one died of an unrelated malignancy, and two had symptomatic recurrences that were subsequently treated for causes other than FPAEs. We demonstrate favorable clinical and hemodynamic results and a low rate of complications for release of FPAES utilizing the medial approach. This surgical approach avoids the complications of delayed wound healing and neuropathy inherent to the posterior approach and may provide comparable functional outcomes for patients with FPAES.
Fenestrated and branched endovascular aortic repair (F/BEVAR) is increasingly used to treat complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs) because of their minimally invasive nature compared with open repair. However, data on outcomes in young patients remain limited. The aim of this study was to report 24-month outcomes in patients ≤65 years of age who underwent F/BEVAR. This retrospective bicenter cohort study included consecutive patients treated for complex abdominal aortic aneurysm or TAAA with F/BEVAR between 2016 and 2023 at Nantes and Rennes University Hospitals. Preoperative, intraoperative, and postoperative data were prospectively collected. Data were compared between patients ≤65 years of age and those >65 years of age. Follow-up analyses were performed at 24 months. Among the 254 patients included, 24.8% were aged ≤65 years (n = 63). In the preoperative assessment, patients ≤65 years more frequently had TAAA (44.4% vs 19.9%; P < .001), a history of aortic dissection (19.0% vs 4.2%; P < .001), and prior aortic surgery (43.0% vs 28.0%; P = .046). Primary technical success was similar between the groups (96.8% vs 94.2%; P = .632). Thirty-day all-cause mortality was 3.2% in patients ≤65 years, similar to that observed in patients >65 years (4.2%; P = .90). Rates of postoperative medical complications within 30 days were also comparable, including acute kidney injury (7.9% vs 8.4%) and paraplegia (1.6% vs 0%). Surgical complications were mainly access related (6.3% vs 4.7%), with no significant difference between groups (P = .57). At 2 years, rates of endoleaks, stent occlusion, and reintervention for any cause were similar between groups. However, endovascular reintervention for branch stent placement was more frequent in patients ≤65 years (30.2% vs 10.5%; P < .001). Twenty-four-month mortality was 13.0% (11.1% vs 13.6%; P = .620). A trend toward greater aneurysm sac regression was observed in younger patients (-10.1% vs -4.4%; P = .10). Overall, outcomes after F/BEVAR were similar in patients ≤65 years of age compared with older patients, despite more extensive aneurysmal disease at baseline. The need for close surveillance of target vessels in these patients is confirmed, consistent with the higher prevalence of underlying and progressive aortic dissection.
Common femoral artery (CFA) exposure is a critical step in many vascular procedures. Although local postoperative complications are well described, their association with long-term high-acuity sequelae remains incompletely characterized. This study aimed to evaluate the relationship between hematoma, seroma, surgical site infection, and wound necrosis/dehiscence, and the subsequent development of acute respiratory failure, acute kidney injury (AKI), stroke (cerebrovascular accident), ST-elevation myocardial infarction, limb loss, and mortality. A retrospective cohort study was conducted using the TriNetX database, identifying patients who underwent CFA exposure. Patients were stratified based on occurrence of hematoma, seroma, surgical site infection, or necrosis/dehiscence within 6 months, and whether they underwent surgical correction of the complication within 3 months. The 1- and 5-year incidences of high-acuity sequelae were analyzed. Propensity score matching controlled for demographics and comorbidities, including hypertension, diabetes, ischemic heart disease, end-stage renal disease, and tobacco use. Relative risk ratios (RRs) with 95% confidence intervals were calculated. Among 129,774 patients, wound necrosis/dehiscence was the most prevalent complication and strongest predictor of long-term adverse outcomes. Complication rates generally peaked within the first postoperative month. Any postoperative complication significantly increased the 1-year incidence of limb loss (RR, 4.43; P < .0001) and AKI (RR, 1.42; P < .0001), as well as the 5-year incidence of limb loss (RR, 3.61; P < .0001), acute respiratory failure (RR, 1.28; P < .0001), AKI (RR, 1.28; P < .0001), cerebrovascular accident (RR, 1.09; P = .027), and mortality (RR, 1.03; P = .044). Patients requiring corrective procedures experienced additional risk, including higher 1-year and 5-year rates of limb loss and AKI. Postoperative groin wound complications after CFA exposure are independently associated with increased long-term systemic and limb adverse outcomes, particularly limb loss and AKI. Wound necrosis/dehiscence demonstrated the strongest association across outcomes. These findings suggest that groin complications represent clinically meaningful markers of downstream risk and identify a critical early postoperative window for intensified surveillance and preventive intervention.
Major injuries to the inferior vena cava (IVC) are associated with high morbidity and mortality. In cases of extensive vascular loss where prosthetic material or autologous venous grafts are unavailable, the use of a fascial autograft represents a viable alternative. We present the case of an 80-year-old male patient with sepsis secondary to pyonephrosis. During nephrectomy, the patient sustained a circumferential infrarenal injury in the inferior vena cava. Owing to the impossibility of primary repair, the lack of available vascular prostheses at the institution, and the patient's hemodynamic instability, an emergency vascular reconstruction was performed using a tubularized autologous graft obtained from the parietal peritoneum and the posterior sheath of the rectus abdominis muscle. Postoperatively, the patient developed segmental graft thrombosis, an expected complication, which was managed conservatively with anticoagulation therapy. Clinical evolution was favorable, with partial recanalization and development of collateral venous circulation. The peritoneofascial autograft combined with the posterior rectus sheath represents a feasible and effective surgical option in vascular emergencies, particularly in contaminated fields, providing satisfactory early outcomes in terms of hemostasis and clinical recovery. Las lesiones mayores de la vena cava inferior (VCI) se asocian con alta morbilidad y mortalidad. En casos de pérdida vascular extensa en los que no se dispone de material protésico o de injertos venosos autólogos, el uso de un autoinjerto fascial representa una alternativa viable. Presentamos el caso de un paciente masculino de 80 años con sepsis secundaria a pionefrosis. Durante la realización de una nefrectomía, el paciente presentó una lesión circunferencial infrarrenal de la VCI. Debido a la imposibilidad de realizar una reparación primaria, la ausencia de prótesis vasculares disponibles en la institución y a la inestabilidad hemodinámica, se llevó a cabo una reconstrucción vascular de emergencia utilizando un injerto autólogo tubularizado obtenido peritoneo parietal y de la vaina posterior del músculo recto abdominal. En el postoperatorio, el paciente desarrolló trombosis segmentaria del injerto, una complicación esperada, la cual fue manejada de forma conservadora con terapia anticoagulante. La evolución clínica fue favorable, con recanalización parcial y desarrollo de circulación venosa colateral. El autoinjerto peritoneo-fascial y de la vaina posterior del recto constituye una opción quirúrgica factible y eficaz en emergencias vasculares, especialmente en campos contaminados, ofreciendo resultados tempranos satisfactorios en términos de hemostasia y recuperación clínica. Vena cava inferior, lesión vascular, autoinjerto peritoneo-fascial, vaina posterior del recto, reconstrucción vascular, nefrectomía complicada, trombosis de la vena cava inferior, cirugía de emergencia, injerto biológico.
A case of late type IA endoleak is reported. The endoleak occurred approximately 1 year after successful treatment of a type IB endoleak with iliac branch device implantation in a patient who had undergone endovascular aneurysm repair 10 years earlier for an abdominal aortic aneurysm with severe neck angulation. The patient underwent secondary endovascular revision, which proved ineffective, with persistence of the endoleak and progressive aneurysm sac enlargement. A minimally invasive open surgical approach with endograft preservation, consisting of external proximal aortic neck banding, was therefore undertaken. Complete resolution of the endoleak was achieved and confirmed intraoperatively by duplex ultrasound. This case highlights the role of aortic neck banding as an effective salvage strategy for type IA endoleak refractory to endovascular treatment and the potential role of duplex ultrasound as a diagnostic gold standard in the intra- and postoperative periods.
Inferior vena cava (IVC) filters are indicated in patients with deep venous thrombos is and a contraindication to anticoagulation and are typically removed when they are no longer needed. Real-world data demonstrate that only a small proportion of IVC filters are retrieved, imposing a risk for IVC thrombosis, occlusion, and post-thrombotic syndrome. Here, we present a case of bilateral IVC filter-associated thrombosis in a patient with duplicated IVC and retained filters, treated with endovascular reconstruction. We also perform a selective review of the literature and highlight the efficiency of endovascular stenting across chronically occluded IVC filters in select patients.
Ruptured ovarian artery aneurysm (OAA) is an exceptionally rare cause of postpartum retroperitoneal hemorrhage and is often difficult to diagnose due to nonspecific presentation. We report a postpartum patient with intermittent symptoms whose computed tomography scan suggested ovarian artery bleeding, followed by an unsuccessful endovascular embolization attempt due to severe vessel tortuosity. She ultimately underwent open surgical exploration with ligation of the ruptured OAA, achieving definitive hemostasis and full recovery. This case highlights the diagnostic challenges of OAA rupture and underscores the importance of prompt operative intervention when endovascular management is not feasible.
Post-thrombotic syndrome (PTS) is a chronic sequela of deep vein thrombosis, often associated with significant morbidity and limited treatment options in advanced cases. The VenaCore thrombectomy catheter (Inari Medical, Irvine California) has been developed to address chronic venous occlusions without the need for stenting. This retrospective single-center review examined the first eight consecutive patients with PTS treated with the VenaCore catheter at our institution between September and December 2024. Clinical data, procedural details, technical success, safety outcomes, and 30-day follow-up imaging and symptom assessment (Villalta score) were evaluated. A comprehensive description of our endovascular approach and device technique is provided. Eight patients (4 female, 4 male; median age 39 years) were treated. The median time since deep vein thrombosis diagnosis was 2 years (range, 6 months to 20 years). All patients had moderate to severe PTS symptoms. Technical success was achieved in seven of the eight patients (88%). The median length of occlusion crossed was 20 cm. A mix of both iliofemoral and femoropopliteal occlusions were treated (4:4). The median VenaCore device time was 10 minutes, with luminal gain observed in all cases. One vessel rupture was encountered (managed successfully). At the 30-day follow-up, treated segments remained patent in six of the seven successfully recanalized patients (86%). Improvement in symptoms was reported by these six patients, with a mean reduction in Villalta score of 4.8 (interquartile range, 4.0-5.0) observed. In our initial experience, the VenaCore thrombectomy catheter demonstrated promising technical performance in improving luminal gain and symptom relief in patients with PTS, with an acceptable safety profile. Further studies are warranted to assess long-term patency and clinical durability.
We report the case of a 79-year-old woman with aortic coarctation previously repaired by extra-anatomic bypass, who developed a late pseudoaneurysm at the distal graft anastomosis. A fully endovascular approach was used, combining an endograft and an Amplatzer Septal Occluder to seal both the pseudoaneurysm and the patent coarctation. The patient recovered uneventfully and remains stable at 1-year follow-up. This case illustrates the safety and efficacy of endovascular techniques for managing complex late complications after aortic coarctation repair.
Chronic total occlusion (CTO) of the superficial femoral artery (SFA) with flush occlusion and complete loss of the true lumen orientation remains a major technical challenge during endovascular interventions. Antegrade crossing may be hindered by ambiguous proximal caps and extensive collateral formation; however, intravascular imaging guidance is not always feasible. The case of a patient with a flush-occluded mid-SFA CTO in whom both antegrade and retrograde guidewire escalation failed to establish true lumen orientation is reported. External vascular ultrasound guidance and bidirectional wiring also fail to reliably identify the true position of the lumen in either direction. To overcome this limitation, an intentional subintimal loop technique using an 0.014-inch guidewire was used to restore spatial orientation and facilitate controlled advancement. Subsequently, a pedal-origin controlled antegrade and retrograde subintimal tracking technique was performed using a 4.0-mm balloon inflated at the popliteal artery, enabling successful guidewire connection and lesion traversal. The occluded SFA was treated with a drug-coated balloon to achieve satisfactory angiographic results. At the 6-month follow-up, computed tomography angiography demonstrated sustained patency of the treated SFA segment and preservation of the pedal access vessel. This case highlights the utility of an intentional subintimal loop technique to regain orientation in complex SFA CTOs when conventional strategies fail and suggests that pedal-origin controlled antegrade and retrograde subintimal tracking using a 4.0-mm balloon may represent a feasible bailout option without compromising distal vessel integrity.
Mesenteric malperfusion in acute type A aortic dissection (ATAAD) carries extremely high mortality. A 53-year-old woman presented with ATAAD and mesenteric malperfusion and was deemed to be at prohibitive risk for central repair. An endovascular-first approach was used to treat visceral malperfusion before central repair. Thermal septotomy was performed to create a proximal landing zone in the descending thoracic aorta, allowing full expansion of thoracic endovascular aortic repair and mitigating the risk of retrograde false lumen pressurization. The distal landing zone in the true lumen provided rapid expansion and visceral reperfusion. Thermal septotomy-assisted thoracic endovascular aortic repair can bridge to central repair in select high-risk patients with ATAAD and mesenteric malperfusion.
Patients with peripheral arterial disease commonly undergo computed tomography (CT) angiography for anatomical assessment, yet body composition data from these scans remain unexploited for treatment planning. We evaluated the feasibility of extracting metabolic phenotype information from routine CT imaging and explored whether baseline body composition parameters might relate to physiotherapy outcomes in this hypothesis-generating pilot investigation. This prospective feasibility study enrolled 10 patients with symptomatic peripheral arterial disease (Fontaine stages IIa-IIb); eight completed a 3-month supervised physiotherapy program consisting of progressive treadmill walking to moderate claudication and resistance training. We performed CT body composition analysis at the L3 vertebral level at baseline and follow-up, measuring the skeletal muscle index (SMI), muscle density in Hounsfield units (HU), visceral adipose tissue area, and subcutaneous adipose tissue area using automated segmentation. Functional assessments included the chair stand test, handgrip strength, and 2-minute walk test. The primary outcome was treatment success (continued conservative management) vs failure (revascularization required). We explored correlations between baseline body composition parameters and functional performance using Spearman rank correlation. CT body composition analysis proved technically feasible in all patients, requiring minimal additional processing time. Five patients (62.5%) achieved treatment success. Baseline muscle density showed correlation with chair stand performance (ρ = 0.829; P = .021), whereas the SMI showed no functional relationships. Visceral adipose tissue was associated in five patients with walking distance (ρ= -0.900; P = .037) and handgrip strength (ρ = -0.775; P = .041). Patients achieving treatment success had a lower body mass index (24.9 kg/m2 vs 29.6 kg/m2) and higher muscle density (41.1 HU vs 35.9 HU). Paradoxically, patients requiring revascularization had higher SMI (59.7 cm2/m2 vs 48.6 cm2/m2) but lower muscle quality. Body composition changes during the intervention showed no relationship to outcomes. This feasibility study demonstrates that metabolic phenotyping using existing CT imaging is technically viable in patients with peripheral arterial disease undergoing physiotherapy evaluation. Exploratory observations suggest testable hypotheses: that muscle quality may prove more functionally relevant than muscle quantity, that visceral adiposity may associate with impaired rehabilitation capacity, and that myosteatotic obesity could emerge as a high-risk phenotype. These preliminary findings support the rationale for adequately powered prospective studies to validate whether CT-based metabolic phenotyping could inform patient selection for the conservative management of claudication.
Endovascular aneurysm repair for ruptured abdominal aortic aneurysms (RAAAs) is technically demanding due to time pressure and distorted vascular anatomy. Cydar Maps artificial intelligence-driven software integrates preoperative computed tomography angiography with live fluoroscopy to enhance procedural guidance. Its application in RAAAs has been limited because of perceived time delays. Yet, this technology could potentially shorten procedure time and reduce radiation exposure and contrast volume. The latter is particularly relevant, given the high incidence of acute kidney injury following RAAAs. This case demonstrates that Cydar Maps was feasible and safe during endovascular aneurysm repair for RAAAs in a hemodynamically stable patient.
Flush infrarenal aortic occlusion presents a significant revascularization challenge. This study evaluated five patients who were treated with direct covered stent implantation via a combined transbrachial and bilateral femoral approach. Technical success was achieved in all cases, with a mean operative time of 88 minutes, and no major perioperative complications occurred. During 3-36 months of follow-up, all patients remained asymptomatic, and imaging confirmed stent patency. Direct covered stent implantation offers a safe and effective one-step endovascular strategy for flush infrarenal aortic occlusion, particularly for patients unsuitable for prolonged thrombolysis or invasive open surgery.
Persistent sciatic artery (PSA) is a rare congenital vascular anomaly that may be complicated by aneurysm formation and distal embolization. A 72-year-old woman presented with acute calf and foot pain despite preserved distal pulses. Computed tomography angiography revealed a complete PSA with aneurysmal degeneration and mural thrombus. Endovascular exclusion using a Viabahn covered stent achieved successful aneurysm exclusion and restoration of distal perfusion. This case demonstrates that endovascular repair is an effective treatment option for PSA aneurysm complicated by distal embolization, offering a safer alternative to open surgery in avoiding sciatic nerve injury.
Inferior phrenic artery aneurysms (IPAAs) are extremely rare, with only 17 reported cases. Most were diagnosed following ruptured, and developed secondary to trauma, surgery, or pancreatitis. We report a case of an asymptomatic unruptured IPAA treated endovascularly. A 73-year-old man without a history of laparotomy, trauma, or pancreatitis had a 6.8-mm saccular IPAA identified incidentally on computed tomography angiography during a comprehensive health checkup. Coil embolization was successfully performed without complications. Given the rarity of IPAAs, a gold standard therapy has not been established. However, endovascular therapy appears to be a safe and effective treatment option.
Budd-Chiari syndrome is a rare cause of hepatic venous outflow obstruction, with heterogenous etiologies. We report the case of a 35-year-old man with chronic, compensated Budd-Chiari syndrome due to retrohepatic inferior vena cava (IVC) occlusion, likely resulting from early-life thrombosis. Imaging and venography confirmed a 3-cm IVC interruption with extensive alternative venous drainage. Endovascular recanalization, balloon venoplasty, and stent placement successfully restored hepatic venous outflow, leading to improvement in hepatic congestion and complete resolution of symptoms. This case highlights the importance of advanced imaging in diagnosing chronic thrombotic occlusion and demonstrates that preserved hepatic venous drainage from chronic venous rerouting may allow successful IVC recanalization/stenting without the need for transjugular intrahepatic portosystemic shunt placement.
The number of individuals undergoing maintenance hemodialysis is rapidly increasing worldwide, accompanied by a rising incidence of central venous stenosis and occlusion, particularly among patients with a history of catheterization. Single-puncture endovascular intervention is generally the preferred treatment approach. We present the case of a 49-year-old male on regular hemodialysis via a functioning right elbow arteriovenous fistula who developed complex stenosis/occlusion involving multiple central venous sites. Due to the challenging venous anatomy and failure of both single- and dual-access techniques, a quadruple-puncture approach was successfully employed to perform balloon angioplasty. This case highlights the value of a personalized and innovative endovascular strategy in managing complex central venous stenosis and occlusion, especially when conventional methods are unsuccessful.