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Impending Arteriovenous Fistula Bleeding With Skin Ulceration

      To the Editor:
      Arteriovenous fistulas are a common form of autogenous access in patients requiring renal replacement therapy.
      Hemodialysis Adequacy 2006 Work Group
      Clinical practice guidelines for hemodialysis adequacy, update 2006.
      • Schmidli J.
      • Widmer M.K.
      • Basile C.
      • et al.
      Editor’s Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).
      • Huber T.S.
      • Carter J.W.
      • Carter R.L.
      • Seeger J.M.
      Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review.
      Aneurysmal degeneration of segments of the outflow vein and outflow stenosis are frequently identified.
      • Kumbar L.
      Complications of Arteriovenous Fistulae: Beyond Venous Stenosis.
      Albeit rare, arteriovenous fistulas bleeding can be a devastating and fatal dialysis access complication. Skin thinning and ulceration are signs of increased risk for bleeding or impending rupture.
      • Georgiadis G.S.
      • Lazarides M.K.
      • Panagoutsos S.A.
      • et al.
      Surgical revision of complicated false and true vascular access–related aneurysms.
      Immediate investigation of the fistula for any concerning signs of bleeding is imperative and any issues should prompt swift referral. Herein we present a case of impending fistula rupture.
      The patient is a man in his mid-60s with a history of end-stage renal disease on hemodialysis secondary to hypertensive glomerulosclerosis. Access for hemodialysis was performed through a right brachiocephalic fistula created nearly 12 years before presentation. The patient had previous history of central outflow vein stenosis, with placement of a cephalic vein stent and several previous balloon venoplasty procedures. At the time of presentation, the patient was having no issues with hemodialysis. During dialysis session, the patient had small volume bleeding from the fistula; physical examination revealed significant skin thinning, a new ulceration, and a punctate area of bleeding (Supplementary Video, available online at http://www.mayoclinicproceedings.org). These findings led to urgent emergency department referral for evaluation and vascular surgery consultation.
      On evaluation, the patient was hemodynamically stable with resolution of the bleeding with compression wrap placed for transfer. There were no stigmata of infection; however, there were signs of skin breakdown with impending hemorrhage, and blood could be seen “swirling” at the base of the wound. The patient was therefore admitted for further fistula revision. Ultrasound evaluation of the fistula showed only mild cephalic vein stenosis, normal flow volumes (1172 mL/min), as well as two aneurysmal segments each measuring 1.7 cm in diameter with the wound originating over the more central aneurysm. Before proceeding to the operating room, a tunneled dialysis catheter was placed, and the patient had a hemodialysis session.
      The cephalic vein was mapped with ultrasound (Figure 1). Two incisions were made before exploring the ulcerated fistula, one central and the other peripheral to the aneurysmal segments. The cephalic vein was isolated and dissected free circumferentially in both exposed segments for vascular control before exposure of the aneurysm. At this point, the incisions were connected and the aneurysmal segments of vein were dissected free (Figure 2). The patient was heparinized, and vascular clamps were applied proximally and distally. The aneurysmal segments were explored. There was a large defect identified in the more central aneurysm with thrombus preventing frank rupture (Figure 3).
      Figure thumbnail gr1
      Figure 1Preoperative wound evaluation and mapping of cephalic vein.
      Figure thumbnail gr2
      Figure 2Surgical exposure of the cephalic vein arteriovenous fistula.
      Figure thumbnail gr3
      Figure 3Full thickness disruption of venous wall of the cephalic vein aneurysm.
      Both aneurysmal segments of the cephalic vein were then opened, plicated, and the excess aneurysmal tissue was resected. A limited endovenectomy was performed to allow for sewing to be performed. The venotomy was then closed in two layers with a running polypropylene suture to a diameter of approximately 6 to 8 mm. After appropriate fore- and back-bleeding, the anastomosis was completed. Flow was restored through the fistula (Figure 4). There was a strong thrill over the fistula and preserved palpable radial pulse distally. The excess soft tissue and thin ulcerated skin were excised. The soft tissue and skin were then closed in multiple layers. Postoperative course was unremarkable, and the patient was discharged home on the second postoperative day. On follow-up, the patient was able to resume dialysis through the reconstructed AVF 2 months postoperatively.
      Figure thumbnail gr4
      Figure 4Endoaneurysmorrhaphy of cephalic vein.
      AVF bleeding is associated with central venous stenosis, large aneurysms/pseudoaneurysms, infection, and skin ulceration.
      • Georgiadis G.S.
      • Lazarides M.K.
      • Panagoutsos S.A.
      • et al.
      Surgical revision of complicated false and true vascular access–related aneurysms.
      • Jose M.D.
      • Marshall M.R.
      • Read G.
      • et al.
      Fatal dialysis vascular access hemorrhage.
      • Ellingson K.D.
      • Palekar R.S.
      • Lucero C.A.
      • et al.
      Vascular access hemorrhages contribute to deaths among hemodialysis patients.
      Fatal vascular access bleeding contributes to 0.4% to 1.6% of deaths in hemodialysis patients, although both fatal and nonfatal bleeding events are believed to be under-reported.
      • Jose M.D.
      • Marshall M.R.
      • Read G.
      • et al.
      Fatal dialysis vascular access hemorrhage.
      • Ellingson K.D.
      • Palekar R.S.
      • Lucero C.A.
      • et al.
      Vascular access hemorrhages contribute to deaths among hemodialysis patients.
      • Blake P.G.
      • Quinn R.R.
      • Oliver M.J.
      The risks of vascular access.
      Up to 40% of fatal vascular access bleeding events are preceded by a herald bleeding event or infection.
      • Ellingson K.D.
      • Palekar R.S.
      • Lucero C.A.
      • et al.
      Vascular access hemorrhages contribute to deaths among hemodialysis patients.
      Clinicians should be able to quickly recognize this entity for appropriate management. Treatment should be expeditious and is usually performed with endoaneurysmorrhaphy and reconstruction, and often patients require additional treatment for central venous stenosis. Our case shows an impending rupture of an arteriovenous fistula that, if left untreated, could have caused catastrophic hemorrhage. Endoaneurysmorrhaphy and plication remain viable treatment modalities to preserve a functional arteriovenous fistula, although this does require a period of temporary dialysis catheter use. We favor this approach over ligation in the appropriate clinical setting.

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      References

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        • et al.
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        • Huber T.S.
        • Carter J.W.
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        Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review.
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        Complications of Arteriovenous Fistulae: Beyond Venous Stenosis.
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        • Lazarides M.K.
        • Panagoutsos S.A.
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        Surgical revision of complicated false and true vascular access–related aneurysms.
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        • et al.
        Fatal dialysis vascular access hemorrhage.
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        • Palekar R.S.
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        Vascular access hemorrhages contribute to deaths among hemodialysis patients.
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