Pseudoaneurysms in Arteriovenous (AV) Fistulas: A Common Complication or a Rare Occurrence?
- Dialysis: Vascular Access
November 03, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
- 803 Dialysis: Vascular Access
- Wyatt, Nicole, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Abudaff, Naief N., Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Salani, Megha, Vanderbilt University Medical Center, Nashville, Tennessee, United States
Although pseudoaneurysms are primarily a complication seen with arteriovenous grafts (AVGs) with repeated localized cannulation, they can more rarely be seen in arteriovenous fistulas (AVFs). The incidence of AVF pseudoaneurysms remains largely unknown and there is limited quality evidence to guide management. We present a case of pseudoaneurysm in a native AVF that required surgical correction.
A 56-year-old male with end stage kidney disease on hemodialysis via right brachiobasilic (BB) AVF presented with two days of shortness of breath and right upper extremity (RUE) swelling. He denied any inciting event or prior difficulty with AVF cannulation. Exam revealed unilateral RUE swelling and a tortuous right BB AVF with palpable thrill and audible bruit. There was no bleeding, ulcerations, or skin breakdown noted. A RUE ultrasound revealed a superficial thrombosis of right basilic vein and a saccular outpouching concerning for a pseudoaneurysm. A fistulagram revealed severe stenosis of right innominate vein requiring venoplasty/stenting, as well as two pseudoaneurysms in the cannulation zone, the largest of which was 2.8 x 2.2 x 1.5cm. Surgery was consulted and recommended against cannulation of AVF given risk of rupture. The pseudoaneurysms were deemed too large for non-invasive treatment, therefore he had a tunneled dialysis catheter placed and underwent prompt AVF revision including pseudoaneurysm resection and conversion to AVG.
This case highlights an important complication of AVFs which impacts patient safety. Though many AVF pseudoaneurysms may be asymptomatic, they pose risks such as rupture and infection. Despite this, the incidence of AVF pseudoaneurysms is scarcely reported and ranges from 0.3% to over 15% in available literature. In addition, there is insufficient literature on treatment results with poorly available evidence and no randomized control trials to guide recommendations for management. Treatment decisions are largely based on access type and etiology of underlying problem, with options including ultrasound-guided manual compression, direct thrombin injection, or surgical options such ligation and excision/repair with graft interposition. We present this case to encourage further research to define AVF pseudoaneurysm classifications, natural history, and optimal treatment guidelines.