Venous stenosis is commonly associated with aneurysms of arteriovenous fistulae
Michael T. Duan, Robert M. Libera, Matthew Altieri, Ajay K. Dhadwal, MD, Joe T. Huang, MD, Michael A. Curi, MD, Timothy Wu, MD.
Rutgers New Jersey Medical School, Newark, NJ, USA.
OBJECTIVES: The optimal management of complicated, true aneurysms of arteriovenous fistulae (AVF), especially those associated with venous outflow stenosis, is not well described. We reviewed our experience in the treatment of complicated AVF aneurysms.
METHODS: We retrospectively reviewed 228 dialysis access patients between 2011 and 2015 at an urban academic medical center and collected patient demographics, comorbidities, indications for, and types of, AVF aneurysm intervention, and postoperative access patency.
RESULTS: Twenty patients underwent treatment of AVF aneurysms. The mean time to aneurysm intervention was 1,140 days (range 376-3,313 days) from the time of AVF construction. Indications for intervention included poor clearances following hemodialysis (7/20, 35%), loss of palpable thrill (5/20, 25%), prolonged bleeding following decannulation (5/20, 25%), and bleeding from skin erosion (3/20, 15%). Interventions performed in the treatment of AVF aneurysm included aneurysmectomy with interposition graft placement (9/20, 45%), aneurysmorrhaphy (1/20, 5%), or fistulogram with endovascular intervention (12/20, 60%). Two patients undergoing fistulogram with endovascular intervention also had concomitant aneurysmectomy, interposition graft, and angioplasty of a central venous stenosis. All but those patients who presented with bleeding from skin erosion underwent a fistulogram (16/20, 80%) and, of these, 12 (60%) were identified to have a concomitant venous stenosis. Ten of those patients with venous lesions responded well to plain balloon angioplasty while two patients required stenting for recalcitrant stenoses. Most patients (17/20, 85%) had a patent, mature AVF following intervention while three accesses thrombosed following their procedures, all of whom had aneursymectomy with interposition graft placement.
CONCLUSIONS: Venous stenosis is commonly associated with true AVF aneurysms. Because of this we suggest a venogram may be prudent in those presenting with issues during hemodialysis or whose physical examination suggests the presence of a venous stenosis. While aneurysmectomy with interposition graft placement is often employed in the repair of AVF aneurysms, we advise caution in proceeding as this appears to be associated with a high risk of access thrombosis.
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