SURGICAL MANAGEMENT OF A LEFT UPPER EXTREMITY ARTERIOVENOUS FISTULA PSEUDOANEURYSM: A CASE REPORT
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Background: An arteriovenous fistula (AVF) is a constructed vascular anastomosis and the first line of vascular access for most patients undergoing dialysis. AVFs need months to mature and the high pressure may lead to local complications such as formation of pseudoaneurysms. Urgent evaluation and repair is needed if the pseudoaneurysm is at risk of rupture. Case Information: A 71-year-old female with an extensive past medical history including ESRD and hypertension presented to the vascular surgery clinic for evaluation of a bleeding left-sided distal AVF pseudoaneurysm measuring 2.4 x 2.1 x 4.5 cm on ultrasound. She elected to have an arteriovenous graft revision and repair of the fistula pseudoaneurysm. In the operating room, a semicircle tunneler was utilized and a polytetrafluoroethylene (PTFE) graft was implanted. The pseudoaneurysm was repaired by ligation technique. The anastomosis was created first in the venous limb and then the arterial limb and the pseudoaneurysm was excluded by repair to allow for thrombosis. At her two week post-operative evaluation in the clinic, the patient appeared to have recovered well. Conclusions: A pseudoaneurysm arising as a complication from chronic hemodialysis is most commonly from routine needle insertion at the site and can be prevented by rotating the access needle during dialysis. The first line non-invasive recommendation is an ultrasound guided manual compression at the neck of the pseudoaneurysm and surveillance. If there is a risk of rupture, guidelines recommend revision of the AVF and emergency ligation, such as in this case report.