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ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 223-228

Incidence of Anastomotic Pseudoaneurysm of Arteriovenous Fistula in Hemodialysis Patients Having Non-Cuffed Catheters as Vascular Access – Association or Causation?


Department of Nephrology, Dr. DY Patil Hospital, Navi Mumbai, Maharashtra, India

Date of Submission14-Mar-2022
Date of Acceptance11-Apr-2022
Date of Web Publication21-Aug-2022

Correspondence Address:
Sameer Vilas Vyahalkar
Department of Nephrology, Dr. DY Patil Hospital, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_18_22

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  Abstract 


Background: Anastomotic pseudoaneurysm affecting arteriovenous fistula created for hemodialysis is an unusual and catastrophic complication. There is lack of clinical data in literature about its incidence and management. Aims and Objectives: To study the incidence and understand the aetiology of anastomotic pseudoaneurysm of arteriovenous fistula (PA-AVF) occurring in first six months after surgery. Materials and Methods: Cohort study based on retrospective analysis of three-year data of case-series of PA-AVF occurring in first six months after AV fistula creation for hemodialysis. Results: Among the 283 AV fistula surgeries (215 distal forearm radio-cephalic AVF and 68 brachial artery or cubital region AVF), 7 patients (2.4%) developed PA-AVF within 1 to 8 weeks after AV fistula surgery. Over-extended dependence on non-cuffed hemodialysis (HD) catheter was a common factor among patients developing this complication. All the patients had a prolonged stay (34 to 75 days) of non-cuffed HD catheters before development of PA-AVF. Diagnosis of HD catheter-related blood stream infection (HD-CRBSI), which overlapped with development of PA-AVF, was proven in 4 patients, two of which also had surgical site infection. One patient had traumatic PA-AVF and in two patients the cause could not be established although features consistent with CRBSI were present. Excision of pseudoaneurysm and ligation of radial artery was done in all cases. Conclusion: Infection is the most common cause of anastomotic pseudoaneurysm of AV fistula. Our study points towards extended use of non-cuffed hemodialysis catehters as a risk factor for development of PA-AVF. Prevention and early aggressive management of CRBSI and surgical site infections along with a limited use of non-cuffed HD catheters for the minimum required duration is the key to reduce the incidence of this complication

Keywords: Anastomotic pseudoaneurysm, arteriovenous fistula, catheter-related bloodstream infection, hemodialysis, noncuffed catheter


How to cite this article:
Vyahalkar SV, Binnani PG, Kulkarni AV, Hoda A, Varyani UT, Nagarik AP, Chaudhari AE. Incidence of Anastomotic Pseudoaneurysm of Arteriovenous Fistula in Hemodialysis Patients Having Non-Cuffed Catheters as Vascular Access – Association or Causation?. Indian J Vasc Endovasc Surg 2022;9:223-8

How to cite this URL:
Vyahalkar SV, Binnani PG, Kulkarni AV, Hoda A, Varyani UT, Nagarik AP, Chaudhari AE. Incidence of Anastomotic Pseudoaneurysm of Arteriovenous Fistula in Hemodialysis Patients Having Non-Cuffed Catheters as Vascular Access – Association or Causation?. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Sep 25];9:223-8. Available from: https://www.indjvascsurg.org/text.asp?2022/9/3/223/354070




  Introduction Top


Vascular access (VA) is considered the Achilles' heel of hemodialysis (HD) for important reasons. Not only is the access vital for the patient on HD, but also it is vulnerable to complications that increase morbidity and mortality of patients with chronic kidney disease (CKD). Overall, arteriovenous fistula (AVF) offers a lower risk of infection, hospitalization, and morbidity to patients on HD as compared to central venous catheters. Despite having a higher risk of infections and increased access-related morbidity, catheters are the most commonly used VA for urgent-start HD, thus earning the label of “necessary evils.”[1] We hereby report our experience on the incidence of anastomotic pseudoaneurysm of AVF (PA-AVF), occurring within a few weeks after surgery in patients undergoing HD through temporary noncuffed HD catheters (NCCs). The concurrent or precedent episode of HD catheter-related bloodstream infection (HD-CRBSI) observed in most of the patients prompted us to think that it could be responsible for this complication by causing metastatic infection and anastomotic dehiscence.


  Case Series Top


After noticing PA-AVF in two patients recently, we retrospectively analyzed the data of patients operated for AVF by a nephrologist at our institute in the past 3 years (January 1, 2019–December 31, 2021) and whose follow-up data were available. The cohort comprised 283 AVFs (side-to-end arteriovenous anastomosis in all) in 277 patients; among them, anastomotic PA-AVF occurred in 7 (2.4%) patients within 1–8 weeks following the surgery. It typically presented with acute onset of painful and progressive swelling over the AVF [Figure 1]a, associated with leukocytosis, and duplex ultrasound revealed a characteristic sac of PA with narrow neck arising from the anastomosis having turbulent to-and-fro flow between the intravascular compartment and the sac [Figure 1]b. Three patients presented with bleeding from the wound following the development of painful swelling, and due to the emergent nature of presentation, Doppler could not be performed and diagnosis was made at the time of surgical exploration. Urgent surgical exploration with excision of the PA [Figure 1]c and [Figure 1]d, ligation of radial artery, and necrosectomy was required in all patients. [Table 1] depicts the patient characteristics. Notable features common to these patients were as follows: (1) all patients had NCCs as VA and had a prolonged stay of catheter (35–75 days) before onset of PA-AVF, (2) all PA-AVFs developed within 3 months after AVF surgery, and (3) in all of these patients, diagnosis of HD-CRBSI, proven or presumptive, was made a few days (7–15 days) before development of PA-AVF. HD-CRBSI was suspected when a patient with NCC developed fever and rigors during or after HD in the absence of clinical evidence of alternative source of infection; in such cases, the protocol dictated broad-spectrum antibiotics to be started after drawing culture. The NCC was removed if the patient was unstable, if symptoms persisted for more than 2 days after starting antibiotics, if exit-site infection was present or if blood culture revealed positive growth. Most of these patients were undergoing HD at peripheral stand-alone HD units that lacked an attending physician or nephrologist, thus possibly the diagnosis of infection was delayed. Due to technical and economic reasons, culture was not obtained in all of the patients. Among three patients who had positive growth on culture, the blood culture was obtained from catheter in two patients, and in one patient, the same organism was isolated from catheter blood culture and blood was obtained from surgical wound. Stringent criteria for the diagnosis of CRBSI have been formed.[2],[3] However, in our study, a definitive diagnosis of CRBSI, as defined by the guidelines, could not be made since paired blood cultures (obtained from both peripheral vein and catheter) were not obtained. By definition, patients with positive blood culture had “probable CRBSI,” defined as positive blood culture obtained from catheter in a symptomatic patient when there was no clinical evidence of alternative source of infection.[3] Those patients who had no alternative source of infection and in whom fever resolved after removal of NCC, but in whom blood culture was not obtained, were labeled to have “suspected CRBSI.” Infective endocarditis was ruled out in patients with positive blood culture.
Table 1: Characteristics of patients who developed pseudoaneurysm of arteriovenous fistula with an indwelling noncuffed hemodialysis catheter

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Figure 1: (a) Anastomotic pseudoaneurysm of AVF presenting as swelling over AVF surgical site in the left distal forearm, (b) Doppler ultrasound reveals the hypoechoic oval pseudoaneurysm with echogenic thrombus at the periphery and turbulent flow at the neck of the pseudoaneurysm (blue arrow), (c and d) the same patient before and after excision of the pseudoaneurysm, (d) the excised capsule of the pseudoaneurysm and the thrombus. AVF: Arteriovenous fistula

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Anastomotic PA-AVF was classified as (1) iatrogenic occurring within the first 6 days after AVF surgery in the absence of other causes, (2) infected having evidence of surgical site infection (SSI) or systemic infection and a positive blood or tissue culture and in the absence of other causes, (3) traumatic, and (4) idiopathic if none of the above causes were found.

Among patients who developed PA-AVF, none had clinical evidence of infection, such as fever or leukocytosis, at the time of surgery. However, bacteremia was probably present in the perioperative period in patient 1 and patient 7. Patient 1 had developed fever and rigors 1 week before AVF surgery, at which point the HD catheter had been changed and he received broad-spectrum antibiotics postdialysis for 1 week, and later, AVF was done. Unfortunately, he developed fever and PA-AVF 1 week after surgery and a blood culture drawn from catheter revealed Staphylococcus aureus. Subsequently, the PA was operated, HD catheter was changed, and antibiotics were given for 6 weeks. It is obvious that he harbored the infection and had been incompletely treated when the AVF surgery was done, thus predisposing him to infected PA-AVF. Patient 7 had developed fever and rigors during dialysis 1 week before AVF surgery; however, the fever subsided with broad-spectrum antibiotics and NCC was not changed as he remained clinically asymptomatic. Seven days after AVF surgery, he developed fever and was noted to have erythema and induration over the surgical site with serosanguinous discharge suggestive of SSI. At this time, blood culture obtained from catheter revealed S. aureus and the NCC was changed while continuing antibiotics. Subsequent course, however, was marked by worsening of SSI and catastrophic presentation with bleeding from PA-AVF [Figure 2]. In none of the other patients was infection evident at the time of surgery and CRBSI developed many days after the AVF surgery in them (13–50 days). In patient 3, PA-AVF was evident a few hours after milking of AVF was carried out by dialysis staff on suspecting acute thrombosis of the AVF which was being cannulated for preceding 1 week; likely, the PA was traumatic in this patient. SSI was observed in the postoperative course of patients 6 and 7. In patient 6, mild SSI was noted 7 days after surgery; it responded well to oral antibiotics and the SSI showed signs of resolution on follow-up at the 15th postoperative day; the patient, however, presented with PA-AVF on the 27th day after AVF surgery. In patient 7, as described above, both SSI and CRBSI possibly contributed to the anastomotic dehiscence and PA-AVF. Considering these facts and the chronology, we believe that SSI was responsible for infected PA-AVF in at least one patient (patient 7), whereas CRBSI led to PA-AVF in three patients (patients 1, 5, and 6) and was associated with the development of PA-AVF in at least three patients (patients 2, 4, and 7) although our data lack the study design to prove a causative association. Some of the limitations to prove causation for this association are as follows – (1) CRBSI was not a definitive diagnosis based on culture reports in all of the patients, (2) tissue cultures were not collected in all except one patient, and (3) Doppler study after creation of AVF to look for hematoma or fluid collection was not done routinely in these patients, the presence of which could also lead to infected PA-AVF.
Figure 2: Anastomotic pseudoaneurysm developing after surgical site infection (a) swelling and erythema over AVF (vertical arrow) and sealed bleeding point at the site of wound dehiscence (horizontal arrow), (b) surgical exploration revealed capsule of pseudoaneurysm, necrotic tissue, and blood clots in the sac, (c) ligated radial artery after surgical excision of pseudoaneurysm sac. AVF: Arteriovenous fistula

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  Discussion Top


While complications of AVF surgery such as thrombosis, wound infection, bleeding, and hematoma are commonly described in the literature, descriptive data on incidence and clinical course of anastomotic PA are rare,[4],[5] whereas cannulation injury-associated PAs of outflow vein segment occurring late in the course of AVF are well characterized. While studies on complications of VA surgery have found anastomotic PAs occurring in grafts at higher incidence rates (2%–10%), the incidence of this complication in autologous AV accesses is reported to be <1% in Western literature.[5],[6],[7] Among studies from the developing world, varying incidence rates are reported in studies that specifically address this complication. Incidence of anastomotic PA-AVF was found to be <1% in the study by Kumar et al.[8] and Gupta et al.,[9] 8.3% in the study by Eldesouky and Fayed,[10] 6%–10% in the study by Mishra,[11] 4.2% in the study by Johny and Pawar,[12] 2.8% in the study by Manne et al.,[13] and 2.5% in an earlier study by our group.[14]

Factors such as sutural dehiscence secondary to hematoma formation, iatrogenic trauma, and hemodynamic factors such as high flow at the anastomosis site may contribute to the formation of PA-AVF; however, the most common cause is infection.[5],[15] Wound infections and CRBSI, as observed in the present study, may be responsible for the PA-AVF.[6] This complication may be attributed to poor hygiene, inadequate sterilization techniques, malnutrition, and prolonged catheter dependence with a higher incidence in some parts of the world.[10],[11] Although HD-CRBSI is known to be responsible for different metastatic infections,[16],[17] we did not find reported incidence of PA-AVF as a complication of CRBSI on review of the literature. It is likely that surgical disruption of the vascular intima by creation of AVF allows bacterial invasion of the subendothelial layer, leading to arteritis and PA formation in the presence of HD-CRBSI.[18]

A striking finding in our study was that all of the PA-AVFs occurred in patients who were operated for distal forearm radio-cephalic AV fistuals (n=215) and none of the patients with cubital region AV fistula (n=68) developed this complication. Similar finding of higher incidence of PA-AVF in distal forearm AVF than proximal AVF was also observed in another study.[11] Few case series from India have reported brachial AVF-associated infected PA-AVF.[19],[20] Proximal arm AVF, as compared to distal AVF, has higher blood flow velocity and shear stress at the anastomosis, thus predisposing it to sutural dehiscence from hemodynamic factors;[5],[21] however, we propose that distal AVFs are more predisposed to metastatic infection and infected PA-AVF as compared to proximal AVFs because of a longer length of arteriotomy, lower velocity of blood flow, and different flow patterns with stagnation of currents at the anastomotic site in distal AVF,[22] thus explaining the findings in our study. A small number of upper arm AVFs in our cohort may also explain the difference in the incidence of PA-AVF between distal and proximal AVFs. Management strategies for PA-AVF include surgical and endovascular repair; however, strategies aimed at salvaging the AVF in the presence of infected anastomotic PA are inadequate and not durable. The most common treatment includes surgical excision of the PA with end-to-end repair or interposition grafting.[19],[20],[21],[23]

PA-AVF is a devastating complication that increases morbidity and inhospital days, exhausts potential sites for AVF, and may have medicolegal implications. Guidelines recommend thorough clinical evaluation for the presence of infection before AVF surgery and prophylactic use of broad-spectrum antibiotics with particular reference to prevent SSI.[24],[25] We think that AVF is a vulnerable site for metastatic infection and hence vigilance is required in patients undergoing HD for the early diagnosis and treatment of HD-CRBSI. Prophylactic antibiotic catheter locking, as recommended by guidelines, should be considered in dialysis units having high incidence of HD-CRBSI. According to the KDOQI guidelines, the use of NCCs should be avoided beyond 2 weeks to reduce infections.[24] However, in countries like India, most of the patients with CKD are seen by nephrologists in advanced stages and initiate urgent-start HD through NCCs[26] and thus are exposed to longer duration of catheter stay. A higher number of catheter days with NCCs must be avoided to prevent infectious complications; in our patients, late referral for AVF, financial constraints, longer wait list for AVF surgery, and individual choice of patients to defer AVF were some of the reasons for longer catheter dependence. The option of tunneled cuffed HD catheters must be considered where a long duration of maturation of AVF is anticipated, as it is associated with lower incidence of CRBSI[26] and provides the infection-free period required for AVF surgery and maturation.

It is also necessary to avoid AVF surgery in the presence of infection. On suspecting CRBSI in the presence of NCC, blood culture should be drawn and broad-spectrum antibiotics with favorable pharmacokinetics should be started.[27] Given the risk of metastatic infections, the NCC should be removed at the earliest,[28],[29] HD should be continued through another catheter at different sites, and AVF surgery should be avoided until blood culture is negative.


  Conclusion Top


Our observations suggest that infections are primarily responsible for anastomotic PAs of the AVF occurring within the first few months of surgery. Both wound infection and CRBSI are common sources of infection in this population. Diagnosis of CRBSI should be actively sought in patients who are undergoing HD through HD catheters and are planned for AVF surgery. VA surgery must not only be avoided in the presence of infections but also until CRBSI is completely treated and bacteremia ruled out. At the same time, a high degree of vigilance is necessary for the early diagnosis and management of CRBSI to avoid infected PA of AVF after AVF surgery in catheter-dependent patients. The role of timely AVF creation to avoid or minimize catheter dependence cannot be overemphasized.

Acknowledgment

We would like to thank Dr. Suhas Bendre, Dr. K.N. Bhosale, and Dr. Sandeep Verma – Cardiovascular and Thoracic Surgeons, Mumbai, and Dr. Sarfaraaz Aalam – Plastic and Reconstructive Surgeon, Mumbai.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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