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OBJECTIVES: Arteriovenous fistula (AVF) aneurysms (AVFA) can lead to skin erosion, bleeding, difficult access while on hemodialysis, and poor cosmetic appearance. We reviewed our experience in treating patients with aneurysmal dilatation of their arteriovenous access and examined the prevalence of significant venous outflow stenoses.
METHODS: We reviewed clinical data of 48 patients (37 men; overall mean age 55 years, range 28-85 years) with an AVFA who underwent treatment during a 30 month period. There were 32 brachial cephalic upper arm, 7 radial-cephalic forearm and 9 brachial-basilic upper arm transposition AVFs. Ninety-six percent of patients suffered from hypertension and 50% had diabetes. All patients underwent a fistulogram prior to open repair. Relevant clinical variables, imaging studies and treatment outcomes were analyzed.
RESULTS: Open repair with aneurysmorrhaphy was performed in either one or two stages in 63% and 37% of patients, respectively. No interposition grafts were used. Only 11 patients (23%) required placement of a tunneled dialysis catheter (TDC) as a bridge until the surgically repaired AVF was ready for use again. Thirty three percent of patients undergoing a one-stage aneurysmorrhaphy required placement of a tunneled dialysis catheter compared to only 6% of patients undergoing a two-stage procedure. Eighty one percent of the AVFs had at least one significant venous outflow obstruction, and 43% of these patients had at least two outflow stenoses that required treatment. A stenosis of the arteriovenous fistula was the most common lesion in 65% of patients followed by a stenosis of the axillary or subclavian vein outflow in 54%, innominate vein stenosis in 17 %, and SVC in 2% of patients. All stenoses were treated with percutaneous balloon angioplasty. All AVFA were salvaged and patients were able to maintain functional use of their access.
CONCLUSIONS: There is a very high association of venous outflow stenoses and AVFA. Comprehensive therapy should encompass treatment of any venous outflow stenoses prior to open AVFA repair. A two-stage repair may decrease TDC use in patients with multiple aneurysms.