Donor Artery Aneurysm Formation following the Ligation of Haemodialysis Arteriovenous Fistula: A Systematic Review and Case Reports

End-to-end anastomosis as a superior repair type to prevent recurrence of arteriovenous fistula aneurysms and improve patency outcomes

BACKGROUND

Arteriovenous fistulae (AVF) complicated by aneurysms are repaired through several mechanisms. Little is known about risk factors for aneurysm recurrence or the efficacy of subsequent repair of recurring aneurysms.

METHODS

About 291 patients underwent AVF aneurysm repair between 2009 and 2019 at a large urban medical center. Patients who underwent staged repair, had a primary graft with pseudoaneurysm, were status-post kidney transplant, or using other dialysis access at the time of repair were excluded. One hundred sixty-two patients were included in the study, of which 52 developed a secondary aneurysm. Chi-square and t-test analyses were used to compare demographics. Multivariate logistic regression was used to examine independent risk factors for aneurysm recurrence. Of the 52 patients with recurrent aneurysms, 41 were repaired again. Patency was examined for each group 1 year postoperatively.

RESULTS

Patients without secondary aneurysms were more likely to have a Charlson Comorbidity Index score ⩾5 (p = 0.045). Males were 2.8 times more likely to develop a secondary aneurysm compared to females (p = 0.023). Patients who underwent elective compared to emergent or urgent surgery for primary aneurysms were significantly less likely to recur (OR = 0.222; p = 0.016). Primary aneurysms repaired by end-to-end anastomosis, compared to aneurysmorrhaphy or graft, were significantly less likely to recur (OR = 0.239; p = 0.041). Among patients with secondary aneurysms, those repaired via end-to-end anastomosis had a significantly higher primary patency rate 1 year postoperatively (p = 0.024). Secondary aneurysm repairs exhibited 1-year primary and secondary patency rates of 51.2% and 82.9%, respectively.

CONCLUSIONS

End-to-end anastomosis reduces risk of recurrence and demonstrates superior patency rates when repairing recurrent aneurysms. It remains unclear why some patients are prone to aneurysm recurrence, however continued attempts to repair existing vascular access are proven to be successful.

Brachial artery aneurysm after hemodialysis fistula ligation: Case reports and review of literature

INTRODUCTION

Brachial artery aneurysm (BAA) following long-standing arteriovenous fistula (AVF) ligation after renal transplantation is odd.

CASE PRESENTATION

Two cases of brachial artery aneurysm treated with bypass (a saphenous vein graft and a PTFE graft). In the first patient no complications were recorded whereas an infection was diagnosed after 6 months from the procedure in the second treatment.

CLINICAL DISCUSSION

Multiple factors activated by stress on the vessel wall followed by fistula ligation are the cause of vascular remodeling of the three layers making up the wall with possible evolution in aneurysmatic lesions. In literature the gold standard for this lesion is the surgical approach, only one endovascular procedure is reported. The traditional surgical approach uses the autologous vein or prosthetic PTFE grafts.

CONCLUSION

Brachial artery aneurysm is a complication that affects patients undergoing renal transplantation who have already undergone AVF ligation. In our experience autologous vein graft represented the best solution.

Inflow Artery Aneurysmal Degeneration After Long Term Native Arteriovenous Fistula for Haemodialysis

OBJECTIVE

Inflow arterial aneurysms are a rare but serious complication after long term arteriovenous fistulae (AVF), probably due to arterial wall remodelling after an increase in flow and shear stress, and kidney transplantation with immunosuppressive therapy. This study aimed to describe the outcomes of surgical treatment and long term follow up in a large cohort.

METHODS

This prospective cohort study collected data from patients with a true inflow artery aneurysm after AVF creation that was surgically repaired between 2010 and 2022. Anastomotic and infected aneurysms or post-puncture pseudoaneurysms were excluded. Demographic data, access characteristics, symptoms, treatment strategies, and long term follow up were recorded; patency was estimated using Kaplan-Meier survival analysis.

RESULTS

During the study period, 28 patients (64% men, mean age 60.1 years) were treated surgically for aneurysmal degeneration of the axillary or brachial (n = 23) or radial (n = 5) artery after an AVF (10 distal, 18 proximal) performed a mean of 18.3 ± SD 7.9 years previously. Most AVFs were ligated or thrombosed, while all patients except one had previously received kidney transplants. Most of the cases (n = 18) were symptomatic: 13 with pain or swelling, four with distal embolisation, and one rupture. They were repaired by aneurysm partial excision and graft interposition (11 great saphenous vein, six ipsilateral basilic vein, three cephalic vein, and two PTFE graft), ligation (n = 3), or direct end to end anastomosis (n = 3). No major complications occurred before discharge, after a mean hospital stay of 2.4 days. After a mean follow up of 4.8 ± 3.3 years, three cases presented complications: two recurrent proximal brachial aneurysms were repaired with an additional proximal interposition graft (one with further late infected pseudoaneurysm) and an asymptomatic post-traumatic graft thrombosis. Five year primary and secondary patency was 84% and 96%, respectively.

CONCLUSION

Aneurysmal degeneration of the inflow artery is an unusual complication during long term follow up of AVFs. Aneurysm excision and, in general, autogenous graft interposition using the saphenous or ipsilateral arm vein is a safe and effective strategy.

Thrombosis related to true axillo-brachial arterial aneurysm following ligation of longstanding arteriovenous fistula for hemodialysis

A 52-year-old man who had received hemodialysis via a left radial-cephalic arteriovenous fistula (AVF) for 18 years presented with severe ischemic symptoms in the left upper arm 12 years after occlusion of the AVF. Diagnostic imaging revealed thrombotic occlusion from a left axillary-brachial artery aneurysm, which required distal bypass surgery. The inflow artery of an AVF can develop aneurysmal degeneration, resulting in upper limb ischemia by embolization or decreased flow, especially with a ligated or occluded AVF or immunosuppressive therapy after renal transplantation. In such cases, the AVF should be monitored, even if ligated or occluded.

Brachial artery aneurysm as a late complication of arteriovenous fistula

INTRODUCTION

Brachial artery aneurysm (BAA) is a rare late complication of arteriovenous fistula (AVF). It brings the risk of peripheral embolism and hand ischemia and is defined by brachial artery diameter above 10 mm or by regional dilatation by >50%. BAA is described in the literature in closed radiocephalic arteriovenous fistulas after kidney transplantation. The aim of the study was to analyze the prevalence of BAA and of their more dangerous forms.

METHOD

A observational one center study performed on patients after kidney transplantation with AVF or arteriovenous graft (AVG). We invited all patients followed up for kidney transplantation in our center. Arterial diameter greater than 10 mm was considered as a brachial artery aneurysm to simplify the detection and evaluation of aneurysms.

RESULTS

About 162 patients with AVF after kidney transplantation were examined between 4/2018 and 4/2020. Brachial artery aneurysm was detected in 34 patients (21%) with AVF or AVG, of them 7 had confirmed wall thrombi. AVF flow volume of more than 1500 ml/min increased the risk of BAA development by 4.54x. Eight aneurysms were treated surgically. After this surgery, the primary patency was 87.5% in 12 months.

CONCLUSION

Brachial artery aneurysm was relatively frequent in our study compare to the literature. Aneurysm or dilatation of the brachial artery is more frequent in functional AVFs. Surgical correction is necessary in cases of complicated aneurysms to prevent distal embolization.

Peripheral embolism as first and only clinical symptom of a true aneurysmal degeneration of the radial artery after ligation of a radiocephalic fistula

True aneurysmal degeneration of the inflow artery after arteriovenous fistula ligation is extremely rare. Pain is the most common symptom and surgical treatment by an autologous venous bypass is considered as the treatment of choice with good long-term results. We present a patient with peripheral embolism as first and only symptom leading to the diagnosis of a true aneurysmal degeneration of the entire left radial artery. It was discovered 5 years after the ligation of his radiocephalic fistula. As illustrated by this case, a conservative treatment by antiplatelet and anticoagulation therapy should be considered a satisfying alternative to the standard bypass surgery in patients with anatomical variations (e.g. an incomplete arterial palmar arch) since the latter include a higher risk of postoperative ischemic complications.

Radial Artery Aneurysm Arising From The Stump Of A Ligated Arteriovenous Fistula In A Kidney Transplant Patient

While aneurysm and pseudoaneurysm are common complications to arteriovenous (AV) fistula, the development of aneurysm from the stump of a ligated AV fistula is unusual. The involvement of radial artery after AV fistula ligation is an extremely rare entity with only two cases reported in the literature. In this report, we describe a 40-year-old kidney transplant patient who presented with a radial artery aneurysm after radiocephalic fistula ligation which was managed by the plastic surgery team using autologous vein graft reconstruction, and we compare our case to the two cases described in the literature in the presentations, timelines, and management options.

Recanalization of thrombosed aneurysmal hemodialysis arterovenous fistulas using a hybrid technique based on data from a single center

Objective

To explore the technical specifications and clinical outcomes of thrombosed aneurysmal haemodialysis arteriovenous fistula (AVF) treated with ultrasound-guided percutaneous transluminal angioplasty combined with minimal aneurysmotomy.

Methods

This case series study included 11 patients who had thrombosed aneurysmal AVF and underwent salvage procedures over a 13-month period. All procedures were performed under duplex guidance. Minimal aneurysmotomy was performed, along with manual thrombectomy and thrombolytic agent infusion, followed by angioplasty to macerate the thrombus and sufficiently dilate potential stenoses. A successful procedure was defined as immediate restoration of flow through the AVF.

Results

The 11 patients (four males and seven females) had a mean age of 49.6 years ± 11.9 years. Six patients (54.5%) had two or more aneurysms. The mean aneurysm maximal diameter was 21.5 mm (standard deviation: ± 5.0 mm), and the mean thrombus length was 12.9 cm (8–22 cm). Ten (83.3%) of the 12 procedures were technically successful. The mean duration of operation was 150.9 minutes (standard deviation: ± 34.2 minutes), and mean postoperative AVF blood flow was 728.6 ml/min (standard deviation: ± 53.7 mi/min). The resumption of hemodialysis was successful in all 11 cases, with a clinical success rate of 100%. The primary patency rates were 90.0% and 75.0% at three and four months over a mean follow-up time of 6.3 months (3–12 months). The secondary patency rates were 90.4% at three and four months.

Conclusion

A hybrid approach combining ultrasound-guided percutaneous transluminal angioplasty and minimal aneurysmotomy might be a safe and effective method for thrombosed aneurysmal AVF salvage.

True Brachial Artery Aneurysm in Patients with Previous Arterio-Venous Fistula Ligation and Immunosuppressant Therapy for Renal Transplantation: Case Report and Literature Review

BACKGROUND/OBJECTIVE

Brachial artery aneurysm (BAA) is a serious complication in patients with previous arterio-venous fistula (AVF), renal transplantation (RT), and immunosuppressive regimens. Until now, there has been no standard of care for these patients, especially for patients undergoing chronic dialysis and immunosuppressive treatment. The aim of this study was to investigate data from the literature regarding these patients and to suggest recommendations for the best approach to their treatment.

METHODS

A review of the literature was performed by searching the PubMed database in the English language. The review was accompanied by two case reports. A total of 24 articles with different variables-demographics, renal transplantation, aneurysm size, and type of surgery-were subjected to the review. In addition, two cases are reported.

CONCLUSION

This review suggests that the best treatment for these patients is open surgery, with aneurysmectomy and graft interposition.

RESULTS

All patients had RT. The age of patients ranged from 26-77 yo, with a male predominance. The majority had an AVF ligated after RT. The main clinical symptoms were pain, swelling, and pulsatile mass (66%). All patients, except one, were treated through open surgery. The first option for treatment was reversed saphenous vein graft interposition (36%), followed by ePTFE graft (16%).

True Brachial Aneurysm in an Older Female Patient. A Case Report and Review of Literature

INTRODUCTION

Brachial artery aneurysms constitute 0.5% of peripheral aneurysms. These can be true or secondary to trauma or arteriovenous fistulas. These present as an asymptomatic pulsatile mass or may cause symptoms due to compression of adjacent neurological structures.

CASE REPORT

We present a review of the literature on clinical, histological, and therapeutic characteristics of true brachial aneurysms, motivated by the case of a 67-year-old woman with an asymptomatic pulsatile mass dependent on the brachial artery of the left arm who underwent open surgical correction with resection of the aneurysmal sac and interposition of great saphenous vein graft with adequate postoperative results.

A dual-plane approach for surgical treatment of pseudoaneurysm with arteriovenous fistula in hemodialysis patients

Background

We report the efficacy of a dual-plane approach using a Dufourmentel skin flap with a purse-string suture of the de-epithelized dermis to manage pseudoaneurysm at the vascular access site for hemodialysis.

Methods

A retrospective analysis was conducted of 61 patients from 2013 to 2018 with pseudoaneurysms at the arteriovenous fistula or graft who were treated with rhomboid excision, vessel repair with a purse-string suture, and a full-thickness Dufourmentel skin flap. The success rate was defined as the probability of complete wound closure and intact vascular access patency without infection or other complications.

Results

The success rate was 93.4% at 6 months postoperatively. Complications included newly occurring pseudoaneurysms (n=2), wound dehiscence (n=1) and bleeding (n=1). There were no complications such as stenosis or thrombosis from the procedure.

Conclusions

A dual-plane approach using a Dufourmentel skin flap with a purse-string suture for vessel repair was shown to be a favorable option for managing stable, small (diameter <2 cm) pseudoaneurysms without infection, rapid expansion, or patency issues of the vascular access.

Giant Brachial Aneurysm after Arteriovenous Fistula Ligation: A Review of the Different Surgical Approaches

The aim of this paper is to describe the case of a patient successfully treated for left brachial arterial aneurysm occurring 15 years after renal transplantation and consequent 8 years after arteriovenous fistula (AVF) ligation. We describe our experience and our surgical approach. A 45-year-old man presented to our attention for a large pulsatile formation on the volatile face of the left forearm, which he reported to have enlarged in the last year. He had a history of chronic renal impairment in 2000, then AVF for dialysis was realized, and he was finally addressed to kidney transplantation in 2004. In 2011 the AVF was ligated. We observed absence of radial pulse and direct flow on the ulnar artery; a large pulsatile formation was evident along the course of the left brachial artery, associated with forearm venous dilatation. Doppler ultrasound showed fusiform aneurysm of the brachial artery with 3.5 cm diameter and longitudinal extension of 5 cm up to the brachial bifurcation. We removed the brachial aneurysm, with a venous bypass on the ulnar artery. The patient was discharged in good general condition on the second postoperative day. At 1- and 6-month follow-up he had complete recovery with graft patency, without any neurological impairment and with a good esthetic result. An open surgical repair with great saphenous vein interposition seems to be the best choice in terms of patency and perioperative morbidity.

Surgical intervention for upper extremity nerve compression related to arteriovenous hemodialysis accesses

Objective:

Chronic renal failure patients with arteriovenous hemodialysis access may exhibit pain and neurological complaints due to local nerve compression by the access conduit vessels of autogenous arteriovenous fistulas or the prosthesis of arteriovenous grafts. In this study, we have examined the results of surgical intervention for vascular access–related nerve compression in the upper extremity.

Methods:

A single center retrospective study was performed of all patients referred for persistent pain and neurological complaints after vascular access surgery for hemodialysis. There were four brachial-cephalic, three brachial-basilic upper arm arteriovenous fistulas, and three prosthetic arteriovenous grafts. All patients had pain and sensory deficits in a distinct nerve territory (median nerve: 6; median + ulnar nerve: 1; medial cutaneous nerve: 1), and two patients had additional motor deficits (median nerve).

Results:

A total of 10 patients (mean age: 59 years; range: 25–73 years; 2 men; 4 diabetics) were treated by surgical nerve release alone (2 patients) or in combination with access revision (8 patients). Mean follow-up was 23 months (range: 8–46 months). Direct complete relief of symptoms was achieved in six patients. Three patients had minor complaints, and one patient had a reoperation with good success.

Conclusion:

Vascular access–related nerve compression is an uncommon cause for pain, sensory and motor deficits after vascular access surgery. Surgical nerve release and access revision have good clinical outcome with relief of symptoms and maintenance of the access site in the majority of patients.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Arterial Aneurysmal Degeneration With Venous Varicosity Following Ligation of an Arteriovenous Fistula in a Kidney Transplant Recipient

Late occurrence of arterial aneurysms following ligation of a hemodialysis arteriovenous fistula (AVF) is rare. Here, we report the case of 51-year-old male patient with an AVF in which arterial aneurysms developed. The patient had undergone left arm radiocephalic (RC) AVF creation for hemodialysis in 2000. He had received a living related donor kidney transplantation from his father in the same year. His RC AVF was ligated in 2009. However, his arm continued to gradually grow in size even after ligation and he visited a hospital for acute pain and erythema around the left elbow in 2017. Since his renal allograft function had been deteriorating, duplex ultrasonography was performed. It revealed 2 giant aneurysms in the distal brachial artery and proximal radial artery with diameters of 3.0 and 2.8 cm, respectively. The superficial veins of the left upper arm showed varicosity and had multifocal thrombi. Microfistula between the artery and vein was revealed by contrast-enhanced ultrasonography and the contrast agent microbubbles flowed from the artery toward the superficial veins. The aneurysms were resected and the arteries were reconstructed with great saphenous vein. There were no perioperative complications and the patient was discharged on postoperative day 3. No complications in the arm or bypass conduit have occurred at 6 months after the surgery.

A Rare Case of Brachial Artery Aneurysm Following Hemodialysis Fistula Ligation in a Transplanted Patient

Aneurysmal arterial dilatation is an infrequent complication following arteriovenous fistula ligation. Herein, we are describing a case in which a 49-year-old transplanted patient developed a true, symptomatic, brachial artery aneurysm 25 years after transplantation and 12 years after ligation of his radiocephalic wrist fistula. Treating strategy included aneurysmectomy and reversed vein interposition using ipsilateral, dilated branch of cephalic vein. Two years postoperatively, the patient remains without complications. Moreover, we mention the pathophysiologic mechanisms that may have contributed to this phenomenon.

Aneurysmal Degeneration of the Brachial Artery after Vascular Access Creation: Surgical Treatment Results

True peripheral artery aneurysms proximal to a longstanding arteriovenous fistula is a well-recognized complication. Late aneurysmal degeneration is rare. This study analyzed the characteristics, therapeutic options, and outcomes of true donor brachial artery aneurysms (DBAA) after arteriovenous fistula (AVF) for hemodialysis. We retrospectively collected the data of patients with DBAA after AVF creation, surgically repaired between January 2001 and September 2015. We excluded patients with pseudoaneurysms, anastomotic aneurysms, and infected aneurysms. We recorded patient's demographics, type of access, aneurysm characteristics, symptoms, treatment, and follow-up. Ten patients were treated for aneurysmal degeneration of the brachial artery. Average aneurysm diameter was 37.5 mm. All cases had, at least, one previous distal AVF, ligated or thrombosed, at the time of diagnosis. The first access was created in mean 137 months before the diagnosis of DBAA. Nine patients had previous medical history of renal transplant and were under immunosuppressive therapy. All patients were symptomatic at the time of diagnosis. In all cases, the treatment was aneurysmectomy followed by interposition bypass. One patient developed a postoperative hematoma with the need of surgical drainage. At 50 months of follow-up, one patient was submitted to percutaneous angioplasty due to an anastomotic stenosis. No other complications occurred during the entire follow-up period (mean: 69 months). The pathogenesis underlying DBAA remains unclear. Increased blood flow after AVF creation, immunosuppressive therapy, and ligation/thrombosis of the AVF may contribute to aneurysm formation. Surgical treatment by aneurysmectomy and bypass, with autogenous conducts, is a safe and effective option.

Aneurysms in Vascular Access: State of the Art and Future Developments

A master class was held at the Vascular Access at Charing Cross (VA@CX2017) conference in April 2017 with invited experts and active audience participation to discuss arteriovenous (AV) vascular access aneurysms, a serious and common complication of vascular access (VA). The natural history of aneurysms in VA is poorly defined, and although classifications exist they are not uniformly applied in studies or clinical practice. True and pseudo aneurysms of AV access occur. Whilst an AV fistula by definition is an abnormal dilatation of a blood vessel, an agreed definition of 18 mm, or 3 times accepted maturation diameter, is proposed. The mechanism of aneurysmal dilatation is unknown but appears to be a combination of excessive external remodeling, wall changes due to injury, and obstruction of outflow. Diagnosis of AV aneurysms is based on physical examination and ultrasound. Venography and cross-sectional imaging may assist and be required for the investigation of outflow stenosis. Treatment of pseudo aneurysms and true aneurysms of VA (AVA) is not evidence-based, but relies on clinical experience and available facilities. In many AVA, a conservative approach with surveillance is suitable, although intervals and modalities are unclear. Avoidance of rupture is imperative and preemptive treatment should aim for access preservation, ideally with avoidance of prosthetic materials. Different techniques of aneurysmorrhaphy are described with good results in published series. Although endovascular approaches and stenting are described with good short-term results, issues with cannulation of stented areas occur and, while possible, this is not recommended, and long-term access revision is recommended.

Giant true Brachial Artery Aneurysm after Hemodialysis Fistula Closure in a Renal Transplant Patient

The usual manifestation of brachial artery aneurysms is the incidental finding of a swelling of the arm, combined with paresthesia or pain in some cases. The etiology is often traumatic or secondary to drug abuse. Pathophysiology of brachial artery dilation in these cases is not completely clear. We herein describe a case of a 61-year-old male presenting with a giant, painful, pulsatile mass on his left arm. He was submitted to a cadaveric kidney transplant in 2005. He had a functioning arteriovenous fistula (AVF) on his right arm, and a spontaneously thrombosed radiocephalic AVF on his left arm. The aneurysm was surgically resected, sparing the median nerve that was totally entrapped and an inverted segment of the basilic vein interposed. At the follow-up, the patient did not present neurological or ischemic disturbs, and the vein graft maintained its patency.