Salvaging the Last Dialysis Access: Cross-Neck Cephalic Arch-to-Contralateral Internal Jugular Vein Bypass for Chronic Total Central Venous Occlusion.

A 65-year-old hemodialysis patient with chronic total occlusion (CTO) of the right brachiocephalic vein and concurrent dialysis access-induced steal syndrome presented with venous hypertension and digital-brachial index (DBI) of 0.42. The brachiocephalic arteriovenous fistula was his sole remaining vascular access. After failed endovascular recanalization, simultaneous extra-anatomic cross-neck cephalic arch-to-contralateral internal jugular vein bypass using a 6-mm polytetrafluoroethylene (PTFE) graft and banding flow reduction were performed. Postoperatively, venous hypertension resolved, DBI improved to 0.78, and steal symptoms remitted. The fistula remained patent at 6-month follow-up, demonstrating combined bypass and flow reduction as an effective salvage strategy for concurrent CTO and steal syndrome.