Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 126-128

Clinical profile of refractory intradialytic hypertension due to a giant AV fistula


1 Department of Nephrology and Hypertension, Deccan College of Medical Sciences, Hyderabad, Telangana, India
2 Owaisi Hospital and Research Centre, Deccan College of Medical Sciences, Hyderabad, Telangana, India

Date of Web Publication3-May-2018

Correspondence Address:
Dr. Sarvepalli Partha Saradhi
Department of Nephrology and Hypertension, Deccan College of Medical Sciences, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_56_17

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  Abstract 


An arteriovenous fistula (AVF) aneurysm extending from the cubital region to the clavicle over the left arm which presented with interdialysis hypertension and high-output cardiac failure showing a reduction of blood pressure and improvement of ejection fraction after the construction of a new AVF in the other arm.

Keywords: Aneurysm, arteriovenous fistula, hypertension


How to cite this article:
Saradhi SP, Ansari Z, Garikipati S. Clinical profile of refractory intradialytic hypertension due to a giant AV fistula. Indian J Vasc Endovasc Surg 2018;5:126-8

How to cite this URL:
Saradhi SP, Ansari Z, Garikipati S. Clinical profile of refractory intradialytic hypertension due to a giant AV fistula. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2021 Dec 8];5:126-8. Available from: https://www.indjvascsurg.org/text.asp?2018/5/2/126/231850




  Introduction Top


Loss of hemodialysis (HD) arteriovenous (AV) vascular access, which may be the result of many complications, is one of the challenging problems in the maintenance of HD patients. In chronic kidney disease, patients on high-flux HD had 5.3-fold higher risk, and patients with diabetes mellitus had 5.8-fold less risk for developing arteriovenous fistula aneurysms.[1]

Hypertension is a common finding in dialysis patients, particularly at initiation.

Many HD patients will require antihypertensive agents. Some dialysis patients are resistant to both volume control and initial antihypertensive medications. Some patients develop paradoxical hypertension in the later stages of dialysis, a time at which most of the ultrafiltration has already been removed. This problem is intermittent in a given patient with a widely variable frequency. The pathogenesis is unclear, although some evidence suggests that altered nitric oxide/endothelin-1 balance and/or endothelial dysfunction may contribute.[2],[3]

This is one such case of intradialytic hypertension associated with the development of a giant AV fistula (AVF) aneurysm and high-output failure.


  Case Report Top


A 30-year-old female who is a known case of chronic kidney disease on HD for the past 4 years due to chronic glomerulonephritis and hypertension, has been having vascular access problems leading to inadequate dialysis. History dates to 2014 when the patient developed anasarca and azotemic symptoms such as nausea, vomiting, and hypertension. Her evaluation showed contracted kidneys with a creatinine of 10 mg/dl, blood urea nitrogen of 149 mg/dl hyperphosphatemia with phosphorous of 6.7 mg/dl, hypocalcemia (corrected calcium of 8 mg/dl), and anemia with a hemoglobin of 8.5 g/dl. She was initially started on dialysis with a right internal jugular catheter and subsequently a left radiocephalic fistula was created. For the first 12 sessions through her radiocephalic fistula, she was having good blood flow rate of 250–300 ml/min and adequate urea clearance with urea reduction ratio (URR) >80 and Kt/V over the next 2 months of 1.2 [Figure 1].
Figure 1: Arteriovenous fistula aneurysm

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Two months later, while cannulating her fistula, there was an abnormal puncture leading to a mild hematoma. After application of cold compress and pressure, the hematoma was subsided. However, progressively over the next three to four sessions, the hematoma started increasing which caused the formation of an aneurysm. She was advised by the treating nephrologist to approach a vascular surgeon for the treatment of aneurysm but due to fear of surgical complications, she declined. Over the next few months, the aneurysm size increased, and her urea clearance and Kt/V worsened to 1.0. She then developed intradialytic hypertension and complained of dyspnea on exertion and orthopnea. After 40 months of initiation of dialysis, she developed angina episodes intradialytic ally. She had a history of orthopnea even after a session of dialysis with ultrafiltration of 3 liters. Her intradialytic weight gain was 3.0–3.5 kg for every 2 days. Her blood flow rate progressively reduced from 250 to 200 ml/minute and her dialysate flow rate had to be reduced from 500 to 300 ml/minute. On evaluation, we found that the blood pressure was 180/100, 220/110, and 230/120 at 1, 2, and 3 h after HD, respectively. There were flow problems and so flow was reduced appropriately. TMP was elevated to 200 mmHg, and there was venous hypertension. She was advised construction of a new fistula or aneurysmectomy. The ejection fraction before initiation of dialysis was 60% but now reduced to 40%.

After counseling the patient, she finally agreed for the construction of a new AVF. Meanwhile, a new internal jugular catheter was placed, and dialysis was managed using the internal jugular vein (IJV). On systemic physical examination, S1, S2, S4 heart sounds were heard, bilateral basal crackles were present. On local examination of the aneurysm, tortuous veins were noted on the surface. It was serpentine in shape with convex and concave anastomotic ends. Its dimensions were 20 cm × 6 cm.

Laboratory values before construction of a new AVF were:

Na – 144 mEq/l, K – 5.3 mEq/l, Cl – 107 mEq/l, Uric Acid – 6.2 mg/dl, and 2D Echo showed ejection fraction of 40% and right ventricular systolic dysfunction.

Color Doppler was done which showed poor AV flow with reduced flow velocities of 136.5 ml per min and absence of any flow distally [Figure 2]. After construction of a new radiocephalic fistula in the patient's right arm, urea clearance improved, intradialytic hypertension resolved, and 2D echo showed an improvement in her right ventricular systolic function with an ejection fraction of 48% and her latest Kt/V was 1.4 and URR 86%. There was no repair of the AVF done for the left hand as the patient was not willing for any repair.
Figure 2: Color Doppler showing flow across the arteriovenous aneurysm

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  Discussion Top


The most common complication of AV vascular access is thrombosis, but other problems such as seroma, extremity swelling, aneurysm/pseudoaneurysm formation, neuropathy, ischemia, heart failure, and infection can also occur. This is one such case report of a giant AVF aneurysm with intradialytic hypertension in a patient after puncture hematoma. The etiology of true aneurysms in AV access is unclear. Proposed etiologies include venous pressure due to central venous stenosis, repeated puncture at the same site, and immunosuppression.[4],[5] In this case, venous hypertension is documented postdialysis which can be contributory in the formation of an aneurysm. Due to high-output failure and poor clearance of urea and uremic solutes, the sodium retention and accelerated renin secretion could have attributed to the development of increased Blood pressure. Increased vascular stiffness and endothelin secretion and high venous hypertension with malfunction of AVF could have caused hypertension. Rotating cannulation sites should reduce the risk of this complication. Aneurysms/pseudoaneurysms are at risk for further complications including rupture, infection, and erosion of the overlying skin. The Kidney Disease Outcomes Quality Initiative guidelines and the 2006 Canadian Society of Nephrology HD guidelines suggest that primary AVFs should be revised when an aneurysm develops if:[6],[7]

  • The skin overlying the fistula is compromised
  • There is a risk of fistula rupture
  • Available puncture sites are limited.


In this particular case, construction of another AVF in the other arm resulted in resolution of the elevated blood pressure.

High-output cardiac failure was also present initially seen as a decreased hematocrit of 26.7%, which after the newly constructed fistula showed an improvement in the ejection fraction. Although heart failure has been attributed to changes in cardiac output, specifically high output, most experts believe that symptomatic heart failure is not commonly associated with an AVF and generally occurs only in patients with underlying cardiac disease.[8]

Heart failure is an important cause of mortality in patients with chronic kidney disease. Data collected by the United States Renal Data System indicated that the risk of death in a dialysis patient with heart-failure is 0.33, 0.46, and 0.57 at 12, 24, and 36 months after initiating dialysis, respectively.[9]


  Conclusion Top


Vascular access failure and aneurysm formation in AV access result in high-output failure, hypertension, and inadequate dialysis. Hence, repair of an aneurysm or change of the access is highly recommended to prevent the associated complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jankovic A, Donfrid B, Adam J, Ilic M, Djuric Z, Damjanovic T, et al. Arteriovenous fistula aneurysm in patients on regular hemodialysis: Prevalence and risk factors. Nephron Clin Pract 2013;124:94-8.  Back to cited text no. 1
[PUBMED]    
2.
Chou KJ, Lee PT, Chen CL, Chiou CW, Hsu CY, Chung HM, et al. Physiological changes during hemodialysis in patients with intradialysis hypertension. Kidney Int 2006;69:1833-8.  Back to cited text no. 2
[PUBMED]    
3.
Inrig JK, Van Buren P, Kim C, Vongpatanasin W, Povsic TJ, Toto RD, et al. Intradialytic hypertension and its association with endothelial cell dysfunction. Clin J Am Soc Nephrol 2011;6:2016-24.  Back to cited text no. 3
    
4.
Woo K, Cook PR, Garg J, Hye RJ, Canty TG. Midterm results of a novel technique to salvage autogenous dialysis access in aneurysmal arteriovenous fistulas. J Vasc Surg 2010;51:921-5, 925.e1.  Back to cited text no. 4
    
5.
Pasklinsky G, Meisner RJ, Labropoulos N, Leon L, Gasparis AP, Landau D, et al. Management of true aneurysms of hemodialysis access fistulas. J Vasc Surg 2011;53:1291-7.  Back to cited text no. 5
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6.
Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006;48 Suppl 1:S2-90.  Back to cited text no. 6
[PUBMED]    
7.
Jindal K, Chan CT, Deziel C, Hirsch D, Soroka SD, Tonelli M, et al. Hemodialysis clinical practice guidelines for the Canadian society of nephrology. J Am Soc Nephrol 2006;17:S1-27.  Back to cited text no. 7
[PUBMED]    
8.
Lazarides MK, Staramos DN, Panagopoulos GN, Tzilalis VD, Eleftheriou GJ, Dayantas JN, et al. Indications for surgical treatment of angioaccess-induced arterial “steal”. J Am Coll Surg 1998;187:422-6.  Back to cited text no. 8
    
9.
US Renal Data System. USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases; Bethesda, MD.; 2012.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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