Don't miss SGLT Tools - PowerPoint slide library for SGLT2 inhibitors

1Division of Nephrology, The Ohio State University, Columbus, Ohio, USA, 2W. G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, NC, USA

 
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

1Fig. (1). 65-year-old male with end stage renal disease and a left forearm radio-cephalic arteriovenous fistula with enlarging aneurysms close to the arterial anastomosis, which were being frequently cannulated for dialysis (puncture sites marked by red circles). Click image to enlarge.

3Fig. (3). (A) Outflow cephalic vein stenosis proximal to the aneurysms. (B) Significant improvement in outflow vein stenosis post angioplasty. Click image to enlarge.

2Fig. (2). Left radio-cephalic fistulogram performed with left brachial artery cannulation demonstrating two aneurysmal areas in the outflow cephalic vein close to the arteriovenous anastomosis. (Luminal size noted in millimeters). Click image to enlarge.

4aFig. (4). Four separate incisions were made in the left forearm (marked by dotted lines). The aneurysmal sac was resected and the cephalic vein was over sewn in a longitudinal fashion leaving adequate caliber lumen for cannulation during hemodialysis. Click image to enlarge.

Introduction

A 65-year-old Asian with history of polycystic kidney disease, hypertension, secondary hyperparathyroidism and end stage renal disease (ESRD) was referred to the interventional nephrologist for high venous pressures during dialysis.

He had been receiving dialysis through a left forearm AV fistula created 15-years ago. The examination of the AV fistula, revealed two large areas of aneurysmal dilatations close to the arterial anastomosis (Figs. 1, 2). The aneurysmal areas were frequently being cannulated for dialysis given the “lack of cannulation sites”. No prior fistulogram was available for comparison. The left forearm fistulogram (with brachial artery cannulation) demonstrated two aneurysmal areas in the outflow cephalic vein close to the AV anastomosis. Additionally, there was 70% stenosis of the outflow vein, 1-cm proximal to the proximal aneurysmal dilatation, which was successfully treated with percutaneous angioplasty for short term benefits (Fig. 3). In view of the large aneurysmal dilatation and lack of suitable additional segment for cannulation, he was referred for a surgical revision. He underwent resection of the aneurysmal sac, along with luminal reconstruction of the outflow cephalic vein (Fig. 4). However, given the lack of adequate cannulation segment, a short term tunneled central venous catheter was placed during the post surgical recovery period.

Arteriovenous fistula is considered the “ideal vascular access” in patients with end stage renal disease (ESRD); however, its creation is not without complications. Aneurysmal dilatation is a poorly defined complication which, can potentially lead to access loss and life threatening hemorrhage. Increased venous pressure due to proximal venous stenosis along with repeated cannulations at the same site, are thought to play a significant role in pathogenesis. Given risk of substantial bleeding, it is recommended to avoid cannulation of aneurysmal area; however, as seen in our patient significant numbers of ESRD patients are at risk of being cannulated in the aneurysmal area. Nephrologist taking care of ESRD patients should be aware of its wide clinical spectrum along with signs of “unstable aneurysms” that would mandate an emergent surgical referral. Fistulogram often identifies a high grade proximal stenosis which can be treated by percutaneous angioplasty and perhaps halt the aneurysm progression. Although, endovascular interventions with stent graft placement can be considered in those with pseudoaneurysms related to arteriovenous grafts, it is often an interim measure in an attempt to prolong access longevity. With new surgical techniques and enhanced expertise, it is now possible to salvage the current AV access while simultaneously preserving the precious venous capital for the future AV accesses.

Acknowledgement

None declared.

Conflict of Interest

The author confirms that this article content has no conflict of interest.

References

[1] Shah R, Bhatt UY, Cleef SV, et al. Vascular access thrombosis and interventions in patients missing hemodialysis sessions. Clin Nephrol 2011; 76(6): 435-9.
[2] Beathard GA. Hemodialysis arteriovenous fistulas. 2003. Retrieved from: www.esrdnetwork.org
[3] Vachharajani TJ. Atlas of Dialysis Vascular Access. 2010 Retrieved from: www.fistulafirst.org.
[4] NKF-K/DOQI Clinical Practice Guidelines for Vascular Access. Am J Kidney Dis 2001; 37(1): S147-8.
[5] Pasklinsky G, Meisner RJ, Labropoulos N, et al. Management of true aneurysms of hemodialysis access fistulas. J Vascular Surg 2011; 53(5):1291-7.
[6] Saeed F, Kousar N, Sinnakirouchenan R, et al. Blood loss through AV fistula: a case report and literature review. Int J Nephrol 2011; 2011: 350870.
[7] Sultana A, Torella F, McWilliams R, et al. Axillary artery aneurysm following closure of haemodialysis fistula: a case report. J Cardiovasc Surg 2007; 48(2):197-9.
[8] Marticorena RM, Hunter J, Macleod S, et al. The salvage of aneurysmal fistulae utilizing a modified buttonhole cannulation technique and multiple cannulators. Hemodial Int 2006; 10:193-
200.
[9] Kronung G. Plastic deformation of Cimino fistula by repeated puncture. Dial Transplant 1984; 13: 635-8.
[10] Konner K, Nonnast-Daniel B, Ritz E. The arteriovenous fistula. J Am Soc Nephrol 2003; 14:1669-80.
[11] Quinn RR, Lamping DL, Lok CE, et al. The vascular access questionnaire: assessing patient-reported views of vascular access. J Vasc Access 2008; 9:122-8.
[12] Lawrence M, Roy-Chaudhury P, Asif A, et al. Surgical salvage of the autogenous arteriovenous fistula (AVF). J Nephrol 2007; 20: 388-98.
[13] Niyyar VD, Moossavi S, Vachharajani TJ. Cannulating the hemodialysis access through a stent graft - is it advisable? Clin Nephrol 2012; 77(5): 409-12.
[14] Salman L, Asif A. Stent Graft for Nephrologists: Concerns and Consensus. Clin J Am Soc Nephrol 2010; 5: 1347-52.
[15] Hong-Yee L, Seck-Guan T. Arteriovenous Fistula Aneurysm – Plicate, Not Ligate. Ann Acad Med Singapore 2007; 36: 851-3.
[16] Karabay O, Yetkin U, Silistreli E, Uskent H, Onol H, Acikel U. Surgical management of giant aneurysms complicating arteriovenous fistulae. J Int Med Res 2004; 32: 214-7.
[17] Woo K, Cook PR, Joy Garg J, et al. Midterm results of a novel technique to salvage autogenous dialysis access in aneurysmal arteriovenous fistulas. J Vasc Surg 2010; 51: 921-5.

*Address correspondence to this author at the Ohio State University, Division of Nephrology, 395 W 12th Avenue, Ground Floor, Columbus, Ohio 43210, USA; Tel: 614 293 6839; E-mail: [email protected]

This material is adapated with permission from The Open Urology & Nephrology Journal

Comments (0)

There are no comments posted here yet

Leave your comments

  1. Posting comment as a guest. Sign up or login to your account.
Attachments (0 / 3)
Share Your Location
ukidneyisup