Impending Arteriovenous Fistula Bleeding With Skin Ulceration

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