|Year : 2020 | Volume
| Issue : 3 | Page : 245-249
Pseudoaneurysms in dialysis access – Outcomes of surgical repair
T Krishna Prasad, Maneesh Sinha, HS Harsha, K Prasannakumar, Venkatesh Krishnamoorthy
Department of Urology, NU Hospitals, Bengaluru, Karnataka, India
|Date of Submission||22-Nov-2019|
|Date of Acceptance||10-Dec-2019|
|Date of Web Publication||12-Sep-2020|
T Krishna Prasad
Department of Urology, NU Hospitals, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Context: This study documents the outcomes of pure surgical attempt to salvage pseudoaneurysms (PSAs) in dialysis access. Considering that the long-term outcomes of surgical salvage are nearly the same as that of stent-graft use, it is possible if sufficient evidence accumulates to suggest that a surgical salvage of PSA can be considered as an equally safe option. Objectives: The literature on pure surgical repair of PSA is sparse. At a reported 6-month patency rate of 75%, open surgical salvage offers a reasonable option for salvaging a vascular access complicated by PSA formation. We report our results of attempted surgical salvage of PSA and an overview of the available literature on the use of endograft and surgical repair of PSA. Methods: This was a retrospective review of all patients presenting with PSA between January 2009 and November 2018. The methods of salvage include primary repair or excision with interposition of graft, the primary outcome being to obtain a functional access. Results: During the above period, of the 1462 fistulae created, 32 (2.1%) presented with PSA. The average time from the access creation to the presentation was 24.26 months. The overall technical salvage rate was 31% (n = 10), with the salvaged fistulae having a 3 patency rate of 60%, the mean follow-up being 14.5 months. Conclusion: About 31% of fistulae with PSA could be salvaged with a 3-month patency of 60%. Surgical salvage therefore appears to be a durable option for PSA in patients undergoing hemodialysis.
Keywords: Aneurysm, arteriovenous fistula, false, operative, surgical procedures
|How to cite this article:|
Prasad T K, Sinha M, Harsha H S, Prasannakumar K, Krishnamoorthy V. Pseudoaneurysms in dialysis access – Outcomes of surgical repair. Indian J Vasc Endovasc Surg 2020;7:245-9
|How to cite this URL:|
Prasad T K, Sinha M, Harsha H S, Prasannakumar K, Krishnamoorthy V. Pseudoaneurysms in dialysis access – Outcomes of surgical repair. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Oct 30];7:245-9. Available from: https://www.indjvascsurg.org/text.asp?2020/7/3/245/294928
| Introduction|| |
For the estimated 229/million end-stage renal disease patients in India, the predominant method of renal replacement therapy is hemodialysis.
Aneurysmal dilatations must clearly be differentiated from the pseudoaneurysm (PSA), while the aneurysmal dilatation is obviously lined by intima; the PSA however is lined by a pseudocapsule formed when blood leaks out of the vessel and is walled off. The reported rate of PSA formation is about 2%–10%,,, however, small; this might seem that it leads to a significant morbidity and may lead to the potential loss of the access.
Practice guideline recommendations of K/DOQI indicate that surgical intervention is needed of enlarging PSA and those that are twice the size of the underlying graft to prevent the risk of rupture.
Accepted methods of managing PSA include, at its worst, ligation of the access with excision of the PSA and using a temporary central vein catheter (CVC), placement of percutaneous covered stents,,, or excision of the PSA and the use of bridging grafts/autologous vein.
A review of available literature revealed a tendency to manage PSA with endovascular stents,,, and sparse literature,, on management by a pure surgical technique. We report our results of attempted surgical salvage of PSAs without the use of any endovascular procedures and the functional outcomes.
| Methods|| |
This is a retrospective review of all the patients managed for PSA from 2009 to 2018. In this period, a total of 1462 fistulae were created, and among these 32 (2.1%) patients followed up with clinical findings of PSA, the diagnosis was confirmed by an ultrasound Doppler; surgical intervention was deemed necessary as majority presented with bleeding and ulceration.
Under appropriate antibiotic cover and tourniquet control, a technique is similar to the “trapdoor” technique described by Kapoulas et al., which was used to dissect the PSA till its pseudocapsule was completely detached from the overlying skin.
In those where there was significant dilatation and erosion of the underlying draining vein, repair comprised excision and polytetrafluoroethylene (PTFE) or free vein graft interposition (when there was no significant mismatch between the donor and recipient vein sizes). Where feasible, small defects were primarily closed using 5-0 prolene. In those patients with grafts, the PSA was drained and the defect in the graft was repaired primarily.
All patients were followed up and underwent clinical examination, ultrasound Doppler at 3 months to assess for the patency.
| Results|| |
During the study period, of the 1462 fistulae created, 2.1% (n = 32) presented with PSA. The mean age of the patients was 55 years (range: 26–88 years). All the patients had a single-site PSA. None of the patients had undergone any previous endovascular interventions.
Demographics and symptoms
Patients presented at a mean of 24.26 months (0–78 months), from the time hemodialysis was initiated through the fistula. The symptoms at presentation included bleeding 46% (n = 15), skin erosion 46% (n = 15), fever 31% (n = 10), ulceration 28% (n = 9), pain in 31% (n = 10), and hypotension 3% (n = 1). The mean size of the PSA was 2.5 cm (1–6.2 cm). About 84% (n = 27) were brachial fistulae and 9% (n = 3) were in grafts (all of these were axillary artery to basilic vein arm loop grafts.).
Nearly 15% (n = 5) of the patients had confirmed bloodstream infection (BSI) at some point during hemodialysis, and of these, 3% (n = 1) presented with a PSA within a month of construction of the fistula. Two patients had more than one episode of BSI; Enterococcus sp. was grown in three and Staphylococcus haemolyticus, Escherichia coli, Klebsiella pneumoniae, Burkholderia cepacia, and Pseudomonas aeruginosa in one each.
In 50% (n = 16) of the patients, there was a significant bleeding by the time the patient present to us, resulting in the surgeon deciding to close rather than salvage the fistula; in 15% (n = 5) of the patients, there were signs of obvious infection; hence, it was decided to close these fistulae. However, the cultures of the tissue sent were all reported as sterile, as these patients were already on antibiotics started by the dialysis team when they presented to us.
Of the 10 patients, 30% (n = 3) were salvaged using interposition graft, 60% (n = 6) underwent pure surgical repair of the PSA and the underlying vein, and 10% (n = 1) underwent the placement of a free vein graft, harvested from the forearm. Of the PSAs which were salvaged using an interposition graft, one graft thrombosed by 3 months and the other 2 patients were lost for follow-up. In those patients in whom a graft was used, a standard PTFE 6 mm nontapered graft was used to bridge the defect.
About 53% (n = 17) were operated using a brachial block, and the remaining were operated under local anesthetic.
About 9.6% (n = 3) of the patients required blood transfusion, one during the procedure in view of hypotension and two after the procedure due to significant anemia.
Only 20% (n = 2) of the patients whose fistulae were salvaged did not need an additional central vein catheter (CVC) and resumed hemodialysis (HD) through the same fistula. The remaining 80% (n = 8) patient's fistulae were rested for an average of 15 days (7–90) days before HD was resumed through the salvaged fistula and the CVC was then removed. About 71% (n = 23) of the patients in all underwent the placement of CVC before or after the salvage procedure.
The overall salvage rate was 31% (n = 10); excluding the 4 patients lost to follow-up, the salvage rate was 21%. Of the remaining 6 fistuale, 5 were being used for HD at 3 and 6 months and one is yet to reach 3 months of use (clinical functionality, as 6 fistulae are being used for HD is 60%). However, excluding the one fistula, the 3-month patency is 50%. Two patients required a fistuloplasty of vein prior to use. The longest duration of patency to date is 2 years and 3 months.
About 35% (n = 11) of the patients later opted to obtain another access created.
Significantly, 50% of the PSA could not be salvaged due to late presentation; it may be possible to have a higher salvage rate if these developing PSAs could have been referred earlier by the dialysis unit.
| Discussion|| |
As seen in literature, PSA complicate anywhere between 2% and 10% of hemodialysis access.,,, Presentation is usually as an emergency, and almost half of our patients presented with bleeding. Salvaging precious arteriovenous (AV) access should be given due consideration even in these often alarmingly dramatic situations.
PSAs need intervention as the resultant complications of ulceration; erosion may eventually result in rupture and in some cases even mortality. In these extreme situations and in the presence of infection, it may be necessary to ligate and close the fistula. A standard method of management has been surgical intervention with revision, with or without placement of prosthetic interposition grafts with an exclusion of the PSA. This is usually followed or preceded by the placement of a temporary catheter for HD.
Endovascular techniques have now become a popular method of managing PSA;,,, a review of the literature reveals that they are the most popular method of managing a PSA in a vascular access.
Numerous theories exist on the reasons for formation of the PSA. Constant use, especially with improper needling techniques, can result in PSAs and in addition, if there is an underlying component of proximal stenosis, this can worsen the clinical scenario. There has also been suggestions that concomitant use of antiplatelets could also aid in the formation of PSA.,
The distribution of PSA was higher in our group with AV fistula (AVF) rather than AV graft (AVG); we believe that this depends on the distribution of AVF/AVG in the prevalent HD patients, though Kinning et al. believe that they occur more in AVG.
While there is a known association between BSI and endartritis leading to PSA formation, we were not able to show a similar finding in our patients.,,, Tissue cultures of all patients in whom the AVF were closed suspecting infection, were reported as sterile.
As mentioned, there appears to be an increasing trend toward the salvage of PSA by the placement of endografts.,,, Analysis of the studies reveals that there is a very good immediate technical success rate ranging from 92% to 100% in the salvage of PSA when endovascular stents are deployed.
However, on follow–up, nearly all the studies reveal different complications resulting in situ ations ranging from recurrent PSA, infection of the stents,, erosion of the stents with explantation, and/or loss of the fistula.
Most studies reporting the salvage of PSA using endografts in dialysis access include both AVF and AVG; Kinning et al. used endovascular stents to salvage over 24 PSA; a majority of their PSAs were in grafts (n = 20) with AVF accounting for only 16% (n = 4). Shah et al. had a nearly equal distribution, AVG PSA 54% (n = 13), and AVF PSA (n = 11). Zink et al. had 44% (n = 17) of their PSAs in AVF. Fotiadis et al. had all their patients present with PSA in AVG (n = 11).
The indication for intervention in all these studies ranged from pain and clinically enlarging PSA, discomfort, skin erosion, PSA with a failed access, and PSA with a diameter twice that of the underlying graft.
Kinning et al. preferred to use the Fluency device (Bard Peripheral Vascular, Tempe, Ariz), as it has larger interstices allowing cannulation through the stent. Similar studies have used other types of stents including Viabahn (W.L Gore and Associates, Flagstaff, AZ),,, Jostent Peripheral Stent Graft (Abbot, Abbott Park, IL),,, and Flair endovascular stent graft (Bard, Tempe, Ariz). The reports of stent fracture by Vesely and Zink et al. have been reported to the rate of 5%, and recurrent PSA formation has also been reported.,, It must also be noted that the use of all these stents is an off-label application in the treatment of PSA.
Looking at the complications, these studies encountered: 12.5%–45% underwent explantation of the stents and 12.5%–20% developed infections. Zink et al. also documented that 15% (n = 6) of the patients who presented with complication had a bleed and 66% (n = 4) of these patients presented with hemodynamic instability.
Infection continues to be a significant problem during the follow-up of patients placed treated with endografts for PSA. Zink et al. suggested after analysis of their patient that the relative risk ratio for developing complications after placement of a stent in a PSA was 5. In addition, in the patients in whom the grafts were explanted, they noted that there was hardly any incorporation of the stents into the tissue that were easily removed. They even have suggested that a chronic inflammatory state that exists in this group of patients may lead to a high overall rate of stent migration. “Each dialysis unit has different needling practices and these stent grafts are difficult to cannulate in the best of setup; to let the patient go back to their respective units without monitoring could lead to even higher complications,” as suggested by Zink et al.
While there is a significant push to “stick” immediately after the endograft is placed, Kim et al. have clearly demonstrated that endografts placed in AVG PSA were more commonly associated with subsequent graft infection and explantation. While it is impossible to regulate all aspects of sterility and techniques in a dialysis unit, it is quite likely that these factors all play a role in infection of the graft.
Attempting to analyze the outcomes of endograft salvage of PSA in AVF alone, we found varied results. Kinning et al., Zink et al., and Shah et al. lost 50% (n = 2), 41% (n = 7), and 9% (n = 1) of their PSAs in AVF to infection.
The immediate technical success in all the groups ranged from 100% to 90%. The 6-month patency, however, declined to 54%,–69%; all studies indicated that the failure rate was higher when endografts were used in AVG rather than AVF. A significant advantage of the endovascular procedure is the ability to treat concomitant proximal stenosis; 63%–56% of the patients in these studies were treated by balloon angioplasty in the same session.
Georgiadis et al.'s work comes closest to what we have done, they reported 44 cases of access complicated by true or false aneurysm all repaired surgically. One problem while reviewing this article was that the outcomes reported were combined for both the true and false aneurysm, thus filtering the data for PSA alone was difficult. A review of their paper reveals that 63% (n = 28) of their aneurysm were PSA. The indications for salvage were nearly identical to all other studies and our own.
All their salvage was conducted under a local anesthetic, which they felt was sufficient.
The PSA developed on an average of 13.9–16.6 months after fistula use in their patients. The mean size of their lesion was 3.64 cm (2–8 cm). The cumulative patency reported by them for the repair in PSA at 3 months was 89.3% and at 6 months 75%. While it is unclear again how many PSA were repaired by autogeneous tissue versus prosthetic (graft) methods, the results when reviewed overall by them revealed that the cumulative patency for the autogeneous technique at 6 months was 76% versus 61% for prosthetic salvage (P = 0.0197). This probably is suggestive that autogeneous tissue repair has better outcomes when compared to prosthetic repair; interestingly, Georgiadis et al. also describe the use of a free vein graft as a salvage method in an aneurysmal/PSA state; both of the above facts are quite similar to the outcomes in our series too where the only remaining patent PSAs are those which were repaired using native tissue. Only 4% (n = 2) of their patients reported with infection.
However, they too point out that the “postintervention primary patency was significantly greater in true revised aneurysm than the corresponding patencies in false revised aneurysm;” indicating that PSAs inherently are difficult lesions to treat.
Understandably, there is a constant endeavor for “less invasive procedures, with lesser use of operating room time, minimal blood loss, low risk of complications, and least patient discomfort.” We believe that the increased adoption of endograft treatment as an option for the management of PSA is a result of this philosophy.
There are certain distinct advantages of this therapy in addition to the above-stated ones, these being: lesser use of bridging catheters, early use of the fistula, and concomitant management of any stenotic lesions.
In contrast, the significant disadvantage is the infection followed by explantation resulting in the loss of the expensive graft, loss of the fistula, and a repeat surgery for the patient. This essentially negates any purported advantage of the endovascular procedure in the first instance, especially with the 6-month patency being the same as that for surgical revision. There is also the issue of restenosis beyond the endograft site which will need to be addressed later.
Surgical repair appears, with all the above background, as a more robust and lasting procedure, with lesser rates of infection and with patency rates which are comparable at 6 months. However, there is the disadvantage of being unable to treat any concomitant lesion and in addition, we do not have a comparative study against endograft use.
| Conclusion|| |
Our experience has shown that the patency rates following a pure surgical approach to repair of PSA in dialysis access is equivalent to the endograft approach. Surgical repair may be considered as another alternative to endograft repair of PSA. However, as the rates of PSA itself are small, a randomized comparison may be difficult unless involving multiple institutions. In addition, the heterogeneous nature of repair also precludes a detailed analysis. We understand the limitations of our study too, especially being retrospective in nature and of a small sample size.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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