Extracranial carotid aneurysm related to pregnancy

Comparison of catheters or new arteriovenous fistulas for commencement of haemodialysis in pregnant women with chronic kidney disease: an international observational study

Background

Evidence surrounding vascular access options for commencing dialysis in pregnancy complicated by chronic kidney disease (CKD) is limited. Creation of new arteriovenous fistulas (AVFs) in pregnant women is rare.

Methods

Retrospective cohort study of approaches to vascular access in pregnancy in centres in Australia, the United Kingdom (UK) and Canada (2002–2018).

Results

Twenty-three women with advanced CKD commenced dialysis in pregnancy (n = 20) or planned to commence (n = 3). Access at dialysis start was a tunnelled catheter (n = 13), temporary catheter (n = 1), AVF created pre-conception but used in pregnancy (n = 3) and AVF created during pregnancy (n = 3). No women commencing dialysis with an AVF required a catheter. No differences in perinatal outcomes were observed comparing AVFs and catheters at dialysis commencement. No AVFs were created in pregnancy in Canadian women. From Australia and the UK, 10 women had a new AVF created in pregnancy, at median gestation 14.5 weeks (IQR 12.5, 20.75). Four women still needed a catheter for dialysis initiation and 3 eventually used the new AVF. Six AVFs were successfully used in pregnancy at median gestation 24 weeks (IQR 22.5, 28.5), 2 were successfully created but not used and 2 had primary failure. No catheter-associated complications were identified except one episode of catheter-related sepsis.

Conclusions

Catheter-related complications were minimal. In selected women, with sufficient pre-planning, an AVF can be created and successfully used during pregnancy to minimise catheter use if preferred. Pre-conception counselling in advanced CKD should include discussing vascular access options reflecting local expertise and patient preferences.

Graphic abstract

Extracranial Internal Carotid Artery Aneurysm in Pregnancy

Isolated extracranial internal carotid artery aneurysms (EICAAs) are rare, accounting for only about .4-4% of all peripheral artery aneurysms. We present a case of an EICAA in a young pregnant patient. To our knowledge, this is the first case being reported of a true EICAA during pregnancy in a multiparous woman. A 25-year-old pregnant patient presented with a pulsatile left neck swelling. Radiological investigations and subsequent surgery during the first trimester confirmed a true saccular left ICA with a maximum diameter of 3.5 cm. She was treated with aneurysm excision and primary anastomosis. She did not have any underlying diseases predisposing to an EICAA. She has been well for 3 years post procedure. It has been postulated that pregnancy could lead to aneurysm development through multiple mechanisms, including hemodynamic, hormonal, and other physiologic changes of pregnancy. Aggressive treatment with surgical intervention is advocated because of the risk of cerebral ischemic complications associated with non-operative treatment, and because satisfactory long-term outcomes can be achieved from surgery.

A large aneurysm in an arterio-venous fistula for renal access in a pregnant young woman

Pregnancy is known to increase the risk of aneurysm formation, likely by a combination of histological changes in vessel walls associated with the hormones of pregnancy and the haemodynamic changes to the circulation. To our knowledge this is the first case of a pregnant woman with a brachial-cephalic arterio-venous fistula (AVF) that had never been needled for haemodialysis, yet became hugely aneurysmal during her pregnancy.