Ultrasound-guided compression repair of pseudoaneurysms complicating a forearm dialysis arteriovenous fistula

Misha Witz1, Miriam Werner2, Jacques Bernheim3,, Ali Shnaker1, Jonathan Lehmann1 and Ze'ev Korzets3

1 Unit of Vascular Surgery and Departments of 2 Radiology and 3 Nephrology, Meir Hospital, Kfar-Saba and the Sackler School of Medicine, University of Tel-Aviv, Tel-Aviv, Israel

Keywords: arteriovenous fistula (AVF); dialysis; pseudoaneurysm; ultrasound-guided compression (UGC)



   Introduction
 Top
 Introduction
 Cases
 Discussion
 References
 
Manual ultrasound guided compression (UGC) has become the initial treatment of choice for post-catheterization pseudoaneurysms of the femoral artery [13]. However, we have found only one report of the use of this technically simple, cost-effective procedure in the treatment of pseudoaneurysms complicating a dialysis arteriovenous fistula (AVF) in the arm [4]. We have recently successfully treated three such patients with UGC resulting in thrombosis of the false aneurysm and salvage of the vascular access. The case details and the technical aspects of the procedure are herein described.



   Cases
 Top
 Introduction
 Cases
 Discussion
 References
 
False aneurysms developed suddenly, during or immediately following dialysis, in established AVFs in three elderly patients with atherosclerotic peripheral arterial disease. Colour duplex ultrasonography (CDU) confirmed the diagnosis. Manual pressure was applied to the pseudoaneurysms, using CDU to monitor flow in the fistulae and in the aneurysms. Pressure was maintained until the aneurysms thrombosed.

Case 1
A 72-year-old woman commenced haemodialysis in August 1994. In November 1994 she was started on long-term aspirin therapy following a transient cerebral ischaemic attack. In January 1995 she developed a pseudoaneurysm of her right brachiocephalic AVF which was treated by surgical ligation with loss of vascular access. A left brachiocephalic AVF was created. In August 1998 the patient developed a pseudoaneurysm (20x15 mm) of her left AVF, presenting as a large haematoma of the upper arm at the end of a dialysis session. On this occasion, under continued aspirin therapy, UGC for 45 min resulted in complete occlusion of the pseudoaneurysm (Figures 1Go, 2Go) with preservation of access patency.



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Fig. 1. Duplex sonography showing blood flow within the venous branch of the fistula (AVF), communicating channel (neck), (arrowhead) and the pseudoaneurysm (P).

 


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Fig. 2. Same picture as above after US-guided compression. Flow has ceased within the neck and the pseudoaneurysm, and is maintained in the fistula.

 

Case 2
A 72-year-old male developed end-stage renal failure due to cholesterol emboli following coronary catheterization. Medications included aspirin at a dose of 350 mg/day. Haemodialysis was commenced in January 1999 via a left brachiocephalic AVF. In July 1999, 3 h into a haemodialysis session, a pulsatile mass rapidly developed at the venous cannulation site. CDU confirmed the presence of a pseudoaneurysm, measuring 28x17 mm (Figure 3Go). Following UGC for 30 min the aneurysm thrombosed. Shunt flow was maintained. The AVF has remained patent and is fully functional. Aspirin therapy was not discontinued.



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Fig. 3. Doppler waveform showing the typical ‘to-and fro’ pattern associated with a pseudoaneurysm with the Doppler gate positioned adjacent to a fluid collection. The diastolic flow (above line) is of lower amplitude and is caused by the elasticity of the soft tissues, forcing blood back into the fistula during diastole when the pressure is reduced. The systolic flow (below line) is caused by the arterial impulse driving blood out from the fistula through the channel and into the collection.

 

Case 3
A 74-year-old male commenced haemodialysis in May 1999 via a left brachiocephalic AVF. The following month, 4 h after a dialysis session at the start of which multiple punctures had been required to establish dialysis, the patient returned with a large pulsatile mass overlying the AVF. Pseudoaneurysm formation (40x20 mm) was confirmed by CDU. UGC was applied for 20 min, resulting in cessation of flow within the aneurysm while maintaining AVF patency.



   Discussion
 Top
 Introduction
 Cases
 Discussion
 References
 
Haemodialysis patients are at high risk of developing iatrogenic pseudoaneurysms because of repeated cannulation of their surgically created AVFs and concomitant heparinization.

In recent years UGC has emerged as the initial treatment of post-angiographic femoral artery pseudoaneurysms [13]. Success rates have varied from 64 to 90% [1,2]. Failure has been related to the size of the aneurysm (>4 cm) and the presence of anticoagulation, although these issues are debatable [2]. A literature review has yielded only two reports of brachial artery [5,6] and one dialysis forearm AVF pseudoaneurysms successfully treated using this method [4]. In the latter case, the size of the obliterated pseudoaneurysm was 2.6 cm. The authors emphasize applying digital compression directly to the neck of the pseudoaneurysm, identifiable by CDU, thus preserving shunt flow. In our patients, manual pressure was exerted over the entire pseudoaneurysm. CDU visualization of fistula flow ensured continued patency of the fistula during compression. The time needed to occlude the pseudoaneurysm ranged from 20 to 45 min. In all cases, vascular access was preserved. There was no recurrence of the aneurysms on follow-up CDU. Continued aspirin administration did not prove to be a hindrance.

Ultrasound-guided manual compression of pseudoaneurysms of forearm dialysis AVF is a safe, effective, non-invasive treatment that should be attempted before resorting to endovascular or open surgical alternatives.



   Notes
 
Correspondence and offprint requests to: Professor J. Bernheim, Department of Nephrology, Meir Hospital, Kfar-Saba, 44281, Israel. Back



   References
 Top
 Introduction
 Cases
 Discussion
 References
 

  1. Fellmeth BD, Roberts ALC, Bookstein JJ et al. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology1991; 178: 671–675[Abstract]
  2. Chua TP, Howling SJ, Wright C, Fox KM. Ultrasound guided compression of femoral pseudoaneurysms: an audit of practice. Int J Cardiol1998; 28: 245–250
  3. Hajarizade H, LaRosa CR, Cardullo P, RohreMJ, Cutler BS. Ultrasound guided compression of iatrogenic femoral pseudoaneurysm failure, recurrence and long term results. J Vasc Surg1995; 22: 425–433[ISI][Medline]
  4. Reichle J, Teitel E. Sonographically guided obliteration of multiple pseudoaneurysms complicating a dialysis shunt. AJR Am J Roentgenol1998; 170: 222
  5. Skibo L, Polak J. Compression repair of a post catheterization pseudoaneurysm of the brachial artery under sonographic guidance. AJR Am J Roentgenol1993; 160: 383–384[ISI][Medline]
  6. Suguwara Y, Koyama H, Miyata T, Sato O. Delayed closure of a post-catheterization pseudoaneurysm of the brachial artery by sonographically guided digital compression (letter). AJR Am J Roentgenol1996; 166: 220[ISI][Medline]
Received for publication: 1. 9.99
Revision received 6. 5.00.