Impending Arteriovenous Fistula Bleeding With Skin Ulceration

医学 动静脉瘘 外科 瘘管 皮肤病科
作者
Nolan C. Cirillo-Penn,Matthew D. Breite,Bernardo C. Mendes
出处
期刊:Mayo Clinic Proceedings [Elsevier BV]
卷期号:97 (8): 1577-1580
标识
DOI:10.1016/j.mayocp.2022.05.032
摘要

Arteriovenous fistulas are a common form of autogenous access in patients requiring renal replacement therapy.1Hemodialysis Adequacy 2006 Work GroupClinical practice guidelines for hemodialysis adequacy, update 2006.Am J Kidney Dis. 2006; 48: S2-S90PubMed Google Scholar, 2Schmidli 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).Eur J Vasc Endovasc Surg. 2018; 55: 757-818Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar, 3Huber T.S. Carter J.W. Carter R.L. Seeger J.M. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review.J Vasc Surg. 2003; 38: 1005-1011Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar Aneurysmal degeneration of segments of the outflow vein and outflow stenosis are frequently identified.4Kumbar L. Complications of Arteriovenous Fistulae: Beyond Venous Stenosis.Adv Chronic Kidney Dis. 2012; 19: 195-201Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar 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.5Georgiadis G.S. Lazarides M.K. Panagoutsos S.A. et al.Surgical revision of complicated false and true vascular access–related aneurysms.J Vasc Surg. 2008; 47: 1284-1291.e5Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar 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 2Surgical exposure of the cephalic vein arteriovenous fistula.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Full thickness disruption of venous wall of the cephalic vein aneurysm.View Large Image Figure ViewerDownload Hi-res image Download (PPT) 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. AVF bleeding is associated with central venous stenosis, large aneurysms/pseudoaneurysms, infection, and skin ulceration.5Georgiadis G.S. Lazarides M.K. Panagoutsos S.A. et al.Surgical revision of complicated false and true vascular access–related aneurysms.J Vasc Surg. 2008; 47: 1284-1291.e5Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 6Jose M.D. Marshall M.R. Read G. et al.Fatal dialysis vascular access hemorrhage.Am J Kidney Dis. 2017; 70: 570-575Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 7Ellingson K.D. Palekar R.S. Lucero C.A. et al.Vascular access hemorrhages contribute to deaths among hemodialysis patients.Kidney Int. 2012; 82: 686-692Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar 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.6Jose M.D. Marshall M.R. Read G. et al.Fatal dialysis vascular access hemorrhage.Am J Kidney Dis. 2017; 70: 570-575Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 7Ellingson K.D. Palekar R.S. Lucero C.A. et al.Vascular access hemorrhages contribute to deaths among hemodialysis patients.Kidney Int. 2012; 82: 686-692Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 8Blake P.G. Quinn R.R. Oliver M.J. The risks of vascular access.Kidney Int. 2012; 82: 623-625Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Up to 40% of fatal vascular access bleeding events are preceded by a herald bleeding event or infection.7Ellingson K.D. Palekar R.S. Lucero C.A. et al.Vascular access hemorrhages contribute to deaths among hemodialysis patients.Kidney Int. 2012; 82: 686-692Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar 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. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxMWMwNzAzZmRjNjFkZDE5ZjNmYmYxYmEzNzhmNjZkNCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcyMjg1NzAxfQ.iot19_QYq7IYCdK62tUs6bBSXl7lgdK2S4l98FeCZnz5qVxGIUt-QJhGi227SwpKFQahZnFZFrmV37cqc_C_nRJtEfHvk47aD4kKQxaRGbnKN8Xq4mOUVlgbgS0nR4hzQoMLbk95jkDSSzdgjpMUrz8D3Kk7XFuwafVPgqLwU0I9QbcrrnugJSKhzuQoyVTYRH982xilUAMAMkNkQ2nX9f9KJPeQ5sf33acxi-iSGL2Dz-e7-ZT9ViLsI-N7ho96X7zV-bZTIwMrpU9i71qZF2V4fK8AQ_CI0Dt9n2un5aFeaTq5bV0fblExYbv9QSirW29ZXvjb8JE5ibkWVxuX1A Download .mp4 (1.28 MB) Help with .mp4 files Supplemental Video
最长约 10秒,即可获得该文献文件

科研通智能强力驱动
Strongly Powered by AbleSci AI
更新
PDF的下载单位、IP信息已删除 (2025-6-4)

科研通是完全免费的文献互助平台,具备全网最快的应助速度,最高的求助完成率。 对每一个文献求助,科研通都将尽心尽力,给求助人一个满意的交代。
实时播报
terryok完成签到,获得积分10
刚刚
Cll完成签到 ,获得积分10
刚刚
聪明的宛菡完成签到,获得积分10
1秒前
CNYDNZB完成签到 ,获得积分10
1秒前
xxj完成签到 ,获得积分10
1秒前
芊芊完成签到 ,获得积分10
2秒前
yar应助bluesky采纳,获得10
2秒前
海人完成签到 ,获得积分10
3秒前
SY15732023811完成签到 ,获得积分10
5秒前
李建勋完成签到,获得积分10
5秒前
科研通AI2S应助一路芬芳采纳,获得10
5秒前
黄花完成签到 ,获得积分10
6秒前
刘珍荣完成签到,获得积分10
7秒前
7秒前
紫金之巅完成签到 ,获得积分10
7秒前
Gang完成签到,获得积分10
8秒前
9秒前
9秒前
10秒前
CYYDNDB完成签到 ,获得积分10
10秒前
粿粿一定行完成签到 ,获得积分10
11秒前
12秒前
战战完成签到,获得积分10
13秒前
xlk2222完成签到,获得积分10
16秒前
笨笨以莲完成签到,获得积分10
16秒前
YHX完成签到,获得积分10
17秒前
沐沐心完成签到 ,获得积分10
18秒前
18秒前
19秒前
哭泣笑柳发布了新的文献求助10
19秒前
轻松白桃完成签到,获得积分10
19秒前
JasVe完成签到 ,获得积分10
22秒前
wakkkkk完成签到,获得积分10
22秒前
含蓄听南完成签到,获得积分10
22秒前
HH给HH的求助进行了留言
22秒前
芋你呀完成签到,获得积分10
23秒前
西蓝花香菜完成签到 ,获得积分10
23秒前
无花果应助兔子采纳,获得10
23秒前
请勿继续完成签到,获得积分10
25秒前
搞怪的婴完成签到,获得积分10
26秒前
高分求助中
【提示信息,请勿应助】关于scihub 10000
Les Mantodea de Guyane: Insecta, Polyneoptera [The Mantids of French Guiana] 3000
徐淮辽南地区新元古代叠层石及生物地层 3000
The Mother of All Tableaux: Order, Equivalence, and Geometry in the Large-scale Structure of Optimality Theory 3000
Handbook of Industrial Diamonds.Vol2 1100
Global Eyelash Assessment scale (GEA) 1000
Picture Books with Same-sex Parented Families: Unintentional Censorship 550
热门求助领域 (近24小时)
化学 材料科学 医学 生物 工程类 有机化学 生物化学 物理 内科学 纳米技术 计算机科学 化学工程 复合材料 遗传学 基因 物理化学 催化作用 冶金 细胞生物学 免疫学
热门帖子
关注 科研通微信公众号,转发送积分 4038184
求助须知:如何正确求助?哪些是违规求助? 3575908
关于积分的说明 11373872
捐赠科研通 3305715
什么是DOI,文献DOI怎么找? 1819255
邀请新用户注册赠送积分活动 892662
科研通“疑难数据库(出版商)”最低求助积分说明 815022