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INTRODUCTION:
Radiocephalic fistulae are the first line recommended arteriovenous access in patients with end stage renal disease. These fistulae have a well-established thrombosis rate.
METHODS:
We report a case of a 45-year-old male who presented to our medical center with a four-week history of right digital blue discoloration. He was initially examined by his primary care physician and started on calcium channel blockers for Raynaud’s Disease. He presented to our emergency department secondary to increasing pain in his digits. Vascular duplex demonstrated triphasic waveforms in his radial artery with associated aneurysm degeneration of the proximal aspects near the arterial anastomosis. His past medical history was significant for kidney transplant with current immunosuppression regiment of mycophenolate mofetil, tacrolimus, and prednisone. He was taken to the operating room and underwent an angiogram confirming distal embolization of the distal digital arteries (Figure 1). There was an aneurysmal degeneration of the proximal stump of the occluded radio-cephalic fistula. The aneurysm resected and the radial artery reconstructed in an end-to-end fashion (Figure 2). Eight milligrams of tissue plasmin activator was placed into the radial artery and injected toward the digits. At clinic follow-up he has decreased vasospasm symptoms in his hand with resolving pain.
RESULTS:
Giant aneurysmal degeneration of brachio-cephalic fistulae in renal transplant patients on immunosuppression has been described in the literature. Corticosteroids have a known association with native artery aneurysmal formation; however, a proposed mechanism is purely speculative. Aneurysmal degeneration of thrombosed radiocephalic fistulae with distal embolization in kidney transplant patients has only been described in three cases in the literature with large ranging durations of immunosuppression (days to years).
CONCLUSIONS:
Aneurysmal degeneration of occluded radio-cephalic fistulae is a rare complication of arteriovenous fistula access. Distal embolization is an even rarer presentation of occluded arteriovenous fistulae. This case study should serve as a warning to physicians following occluded arteriovenous fistulae in transplant patients on immunosuppression.