Case Report
Iatrogenic Brachial Artery Pseudoaneurysm Repair in a Patient with Prior Distal Revascularization and Interval Ligation Procedure
Kochupura PV*, O’Gorman NF, Lance LM and Zickler RW
Department of Vascular Surgery, CaroMont Regional Medical Center, USA
*Corresponding author: Paul V. Kochupura, Department of Vascular Surgery, CaroMont Regional Medical Center Gastonia, NC 28054, USA
Published: 12 Jul, 2016
Cite this article as: Kochupura PV, O’Gorman NF, Lance LM, Zickler RW. Iatrogenic Brachial Artery Pseudoaneurysm Repair in a Patient with Prior Distal Revascularization and Interval Ligation Procedure. Clin Surg. 2016; 1: 1055.
Abstract
Distal Revascularization With Interval Ligation (DRIL) is a proven method to resolve symptoms of
ischemia related to dialysis access.
We present the management of patient with a large brachial artery pseudoaneurysm as an unusual
complication in a patient who had previously undergone a DRIL procedure for ischemia. Inadvertent
access of the brachial artery bypass occurred during routine dialysis, resulting in a five centimeter
brachial artery pseudoaneurysm. Surgical repair of the pseudoaneurysm was performed with a reoperative
brachial artery bypass resulting in patency of the fistula and revascularization of the hand.
Risk factors and management options for this unusual complication are discussed.
Case Presentation
The patient is a 56 year old female who had undergone a Distal Revascularization With Interval
ligation (DRIL) procedure twelve months after arteriovenous fistula creation. Her initial access was
a right arm basilic vein transposition with arterial inflow from her brachial artery. At the time of the
DRIL procedure, she was experiencing severe hand pain at rest without tissue loss. Her Body Mass
Index (BMI) was 38kg/m2. Pulse volume examination revealed a 50 mmHg pressure gradient in the
right hand with compression of the fistula. Saphenous vein was used for the DRIL procedure with
the proximal anastomosis situated 8 cm proximal to the fistula. Ligation of the right brachial artery
was performed with serial silk ties buttressing a metallic clip. The patient’s post operative course was
uncomplicated with resolution of symptoms and continued use of the fistula for dialysis.
Eighteen months later, the brachial artery bypass was inadvertently cannulated during a routine
dialysis session. This resulted in an immediate hematoma and pain. Further attempts at dialysis
were aborted, and the patient was sent home from the dialysis facility with a hemostatic pressure
dressing over the site.
The hematoma failed to resolve and the fistula had a diminished thrill. Fistulogram was obtained
and demonstrated poor flow secondary to an outflow stenosis, in addition to a large arterial
pseudoaneurysm (Figure 1). CT angiogram of the right arm demonstrated a 5.0 cm pseudoaneurysm
with compression of the AV fistula prompting vascular surgery consultation (Figure 2).
The patient was taken to the operating room for surgical repair. The arterial bypass from
the prior DRIL procedure was exposed proximal and distal to the pseudoaneurysm. The patient
was fully anticoagulated with heparin. Using reversed saphenous vein, the pseudoaneurysm was
repaired using interposition grafting with end to end anastomoses proximally and distally. The
thrombus within the pseudoaneurysm was manually evacuated with external compression. The
remnant autogenous conduit was not excised. Interim dialysis was continued using a tunneled
dialysis catheter. The patient’s post operative course was complicated by nausea secondary to severe
gastroparesis. She was treated with intravenous Reglan with resolution of her symptoms. She was
discharged to home on post operative day six.
Post operative CT angiography confirmed patency of the bypass, exclusion of the
pseudoaneurysm, and preservation of the fistula (Figure 3). A high grade stenosis seen in axillary
portion of the basilic vein transposition fistula was treated with balloon venoplasty, with subsequent
cannulation of the access for dialysis. One year later, both her access and her bypass remain
functional and patent. The authors obtained permission for publication from the patient.
Figure 1
Figure 1
Top image: Fistulogram imaging of the basilic vein transposition
fistula. Faint opacification of the pseudoanuerysm is seen on the left. The
venous outflow stenosis is not seen in this image. Bottom image: Magnified
image of the flow channel of the pseudoaneurysm originating from the arterial
bypass.
Figure 2
Discussion
The incidence of End Stage Renal Disease (ESRD) has shifted over
the last decade. It’s incidence increased in the 1990s and early 2000s,
leveled off in the first decade of 2000, and then decreased between 2010
and 2011 [1]. It is estimated there are 700,000 patients in the United
States currently on hemodialysis [2]. Despite a strikingly high (20%)
annual mortality on all hemodialysis patients reported by Collins et
al. [3] in 2010, a more recent report suggests that improvements in
health care delivery have resulted in enhanced survival in dialysis
patients [4].
Dialysis access Associated Steal Syndrome (DASS) is a complication
of ArterioVenous (AV) access surgery where the imbalance between
the low-resistance outflow in the venous system and the high
resistance outflow in arterial circulation results in forearm or hand
ischemia [5]. DASS can affect 10-20% of AV access constructions and
can develop in the immediate post operative period or insidiously
[6,7]. With improved survival in dialysis patients as suggested by Van
Walraven et al. [8], it may be observed that DASS may also increase
over time. In our case, our patient developed symptoms of DASS
twelve months after her initial dialysis access was created. Symptoms
of DASS range from coolness of the extremity to neurological deficits
(parasthesias or weakness), ischemic rest pain, digital ulceration, or
digital gangrene.
A classification system for DASS has been previously described
by Sidawy et al. [9]. This classification system has three grades. Grade
1 DASS (mild) is associated with few symptoms other than a cool
extremity, and requires no treatment. Grade 2 DASS (moderate)
manifests with intermittent ischemia during dialysis, and intervention
is usually required. Grade 3 (severe) presents with ischemic pain at
rest and/or or tissue loss, and intervention is mandatory [9].
The diagnosis of DASS is largely clinical, based on accurate
history and physical examination. Adjunctive testing which may
confirm the diagnosis includes: duplex ultrasound of the arterial
inflow, ultrasound of the access with and without compression, pulse
volume recordings of the access with compression and arteriographyeither
catheter based or with CT imaging [10].
Numerous surgical or catheter based interventions for the
management of DASS have been described. These include: treatment
of arterial inflow obstruction, banding of the access, revision using
distal inflow, proximailization of arterial inflow, ligation of the access,
radial artery ligation, embolization of venous outflow branches and
the DRIL procedure [11,12]. More recently, the DRIL procedure is
increasingly being recognized as the preferred method of treatment
in DASS [13]. While results have been varied, most success occurs in
those patients with early steal.
Secondary complications of the DRIL procedure have been
reported. Some of these include failure to resolve symptoms or
subsequent thrombosis of the arterial bypass component [14].
Arterial pseudoaneurysm related to inadvertent puncture of the
brachial artery bypass is an unusual complication of a surgical repair
for DASS. Factors that may increase this risk include: multiple
operations with failed AV access on the ispsiateral arm (resulting
in erroneous tactile feel by the staff cannulating the access), central
venous stenosis increasing the pulsatility of the access (making the
access and the bypass difficult to distinguish), access that lies medially
on the arm, obesity, ispialteral arm swelling and inexperienced staff
at the dialysis center,.
Options for management of arterial pseudoaneurysms include
observation, thrombin injection, and placement of a covered stent
graft or open repair. Options for open repair include direct repair,
patch angioplasty or interposition grafting with autogenous or
prosthetic conduit.
In this patient, we opted for interposition grafting based on
the size and location of the pseudoaneurysm. The authors felt that
covered stent placement would not result in long term patency.
Furthermore, covered stent placement was felt to be inappropriate
given the pseudoaneurysm’s proximity to the elbow. Thrombin
injection would place the extremity at increased risk for ischemia and
would not resolve compression of the AV access.
Other factors that may have contributed to the inadvertent access
in this patient include the length of the transposed vein at the time of
the original access surgery and her morbid obesity. A shorter segment
of transposed vein and an obese upper extremity resulted in the access
lying medially in the arm. This, coupled with a subsequent outflow
stenosis resulted in increased pulsatility in the access, may have led
to difficulty distinguishing it from the bypass component of the DRIL
procedure. Taken together, these factors may have resulted in the
erroneous cannulation with subsequent pseudoaneurysm formation
in this patient.
To minimize the risk of improper cannulation, patients who
undergo a DRIL procedure should be carefully followed for central
or venous outflow stenoses, which could lead to increased pulsatility.
Upper extremity swelling or persistent bleeding after decannulation
are highly suggestive of a venous stenosis and should warrant further
investigation. In these patients, the authors would suggest early
intervention if a venous outflow stenosis is found.
Herein, this case report presents the management of an unusual
complication of a DRIL procedure for DASS. Predisposing factors for
this complication include previous ipsilateral failed access, central
venous stenosis, access located on the medial aspect of the proximal
arm, edema and dialysis staff experience. Heightened surveillance for
central stenosis, routine duplex surveillance of the access and arterial
bypass and staff education should be collectively used to manage this
specific subset of dialysis patients.
Figure 3
Figure 3
CT angiography after repair. The revised arterial bypass is patent,
supplying inline flow to the hand. Green arrow: Ligated native brachial artery.
Blue arrow: Venous outflow stenosis. The venous stenosis was subsequently
treated with balloon venoplasty.
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