Late Occurrence of a Large Brachial Artery Aneurysm following Closure of a Hemodialysis Arteriovenous Fistula

doi:10.1007/s10016-006-9050-y

Annals of Vascular Surgery

Volume 20, Issue 4, July 2006, Pages 533-535

https://doi.org/10.1007/s10016-006-9050-y Get rights and content

After the pioneer observations by Hunter more than two centuries ago, recent reports have expanded our knowledge about the occurrence and pathophysiology of arterial abnormalities associated with long-lasting hemodialysis arteriovenous fistula (AVF) after its closure. Observed abnormalities include arterial dilatation and aneurysm formation proximal to the site of the repaired AVF. We describe here a patient who developed, after long-lasting hemodialysis AVF, a pan-arterial dilatation with a large brachial artery aneurysm, which was successfully treated with a polytetrafluoroethylene bypass graft.

Section snippets

CASE REPORT

A 58-year-old man was admitted to our hospital with a large pulsating mass in the left arm. He smoked from 18 to 29 years of age and additionally presented with diabetes and hypertension. At 29 years of age, because of renal failure, he started hemodialysis via a left Brescia-Cimino AVF, then substituted for a proximal bypass-graft AVF. At 42 years of age, he was transplanted and the fistula was closed. Thirteen years later, the patient noted the development of a pulsating mass in his left arm,

DISCUSSION

The normal diameter of the brachial artery varies from 3.5 to 4.3 mm for women and from 4.1 to 4.8 mm for men.⁹ Recently, Eugster et al.⁷ reported a statistically significant increase in the arterial diameter following hemodialysis fistula closure and renal transplantation. The dilatation of the brachial artery seems to be time-dependent. This can probably be explained with a combination of factors: increased flow in the vessel,2, 6, 7 endothelium-derived factors⁸ as a product of the shear

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Cited by (23)

Brachial artery aneurysm after hemodialysis fistula ligation: Case reports and review of literature
2024, International Journal of Surgery Case Reports
Brachial artery aneurysm (BAA) following long-standing arteriovenous fistula (AVF) ligation after renal transplantation is odd.
Two cases of brachial artery aneurysm treated with bypass (a saphenous vein graft and a PTFE graft). In the first patient no complications were recorded whereas an infection was diagnosed after 6 months from the procedure in the second treatment.
Multiple factors activated by stress on the vessel wall followed by fistula ligation are the cause of vascular remodeling of the three layers making up the wall with possible evolution in aneurysmatic lesions. In literature the gold standard for this lesion is the surgical approach, only one endovascular procedure is reported. The traditional surgical approach uses the autologous vein or prosthetic PTFE grafts.
Brachial artery aneurysm is a complication that affects patients undergoing renal transplantation who have already undergone AVF ligation. In our experience autologous vein graft represented the best solution.
Surgical Treatment of Multiple Venous and Arterial Aneurysms Due to Arteriovenous Malformations of the Arm
2024, EJVES Vascular Forum
Arteriovenous malformations (AVMs) are rare, especially in elderly patients. Occasionally, AVM can produce aneurysmal degenerations, which can lead to bleeding or rupture. The aim of this case report was to describe the surgical treatment of large arterial and venous aneurysms in the arm associated with an AVM.
An 83 year old woman of White ethnicity who was a non-smoker presented with a large pulsatile aneurysm at the left elbow with paresis of the first three fingers. The diagnosis was made by duplex ultrasonography (DUS), computed tomography angiography (CTA), and arteriography. Additional tests confirmed aneurysms of the brachial artery and the outflow veins, with the largest more than 7 cm in diameter. A very proximal brachial artery bifurcation and increased venous flow were noted. DUS confirmed the AVM by showing continuous flow in the axillary vein. The decision for surgical resection involved vascular surgeons, radiologists, angiologists, and anaesthetists. Treatment involved opening and excision of multiple venous aneurysms and AVMs. A short segment of the aneurysmal brachial artery was also resected and repaired with end to end anastomosis. The deep brachial artery which supplied AVMs and venous aneurysms was ligated and excision of these lesions was performed. At one year follow up, there were no complications and the revascularisation was patent.
Arterial and venous aneurysms occurring together with AVMs are rare and not well documented in the medical literature. In this case, surgical intervention, including resection with direct anastomosis of the arterial aneurysm coupled with excision of venous aneurysms and AVM, proved to be effective, as evidenced by stable post-operative outcomes after one year.
Thrombosis related to true axillo-brachial arterial aneurysm following ligation of longstanding arteriovenous fistula for hemodialysis
2023, Journal of Vascular Surgery Cases, Innovations and Techniques
A 52-year-old man who had received hemodialysis via a left radial–cephalic arteriovenous fistula (AVF) for 18 years presented with severe ischemic symptoms in the left upper arm 12 years after occlusion of the AVF. Diagnostic imaging revealed thrombotic occlusion from a left axillary–brachial artery aneurysm, which required distal bypass surgery. The inflow artery of an AVF can develop aneurysmal degeneration, resulting in upper limb ischemia by embolization or decreased flow, especially with a ligated or occluded AVF or immunosuppressive therapy after renal transplantation. In such cases, the AVF should be monitored, even if ligated or occluded.
A case of aneurysmal dilation of a brachial artery after venous outflow resection
2018, Journal of Vascular Surgery Cases and Innovative Techniques
Dilation throughout the brachial artery in the setting of an arteriovenous fistula is a common occurrence, but focal aneurysmal dilation is not often visualized. Progressive enlargement of a focal arterial segment warrants intervention before negative sequelae. We present the case of a 38-year-old man with history of left upper extremity brachiocephalic fistula who had an enlarged brachial artery and progressive aneurysmal dilation of the distal aspect after ligation and excision of a dilated venous outflow component. The patient was successfully treated with resection and end-to-end reconstruction of the brachial artery, with resolution of pain and improvement in the functionality of his extremity. This case highlights the possible challenges encountered in such situations, when the anatomy is so distorted that it is difficult to clearly delineate on preoperative imaging.
True Brachial Artery Aneurysm after Arteriovenous Fistula for Hemodialysis: Five Cases and Literature Review
2017, Annals of Vascular Surgery
Citation Excerpt :
All our patients underwent renal transplantation and continued an immunosuppressive treatment. The average duration until AD's diagnosis after the transplant was 17.4 years (range 15–21), meaning almost 2 times later than in series reported by Sako or Marzelle,6,30 but similar to the data found in different reported cases.9–25 The average age at the time of hemodialysis access creation of our patients was 26 years, while in the literature it was 34 years.
The donor artery after a long-standing arteriovenous fistula (AVF) for hemodialysis usually evolves exceptionally toward a true aneurysmal degeneration (AD). The purpose of this article was to describe true brachial artery AD in end-stage renal disease patients after AVF creation, as well as its influencing factors and treatment strategies.
We present a retrospective, observational, single-center study realized in Caen University Hospital’s Vascular Surgery Department from May 1996 to November 2015. The inclusion criteria were true AD of the brachial artery after a vascular access for hemodialysis. A literature research, using the same criteria, was performed on the articles published between 1994 and 2015. The used databases included MEDLINE (via PubMed), EMBASE via OVID, Cochrane Library Database, and ResearchGate.
Our series includes 5 patients. Twenty-one articles were found in the literature: 17 case reports, 3 series, and 1 review. The same triggering factors for AD (high flow and immunosuppressive treatment) were found. The mean age at the time of AVF creation, first renal transplantation, and AD's diagnosis were respectively 26 (range 15–49), 29.2, and 48.6 years (range 37–76) in our series versus 34 (range 27–39), 40.4 (range 28–55), and 55.5 years (range 35–75) in cases found in the literature. The time spread after AVF creation and aneurysmal diagnosis was about 20.6 years (range 18–25) in our study versus 20.5 years (range 9–29) in the case reports. Our surgical attitude corresponds principally to that described in the literature. Nevertheless, we describe for the first time one case of arterial transposition to exclude the brachial aneurysm using superficial femoral artery.
Arterial aneurysm is a rare, but significant complication after a long-term creation of hemodialysis access. High flow and immunosuppression may accelerate this process. Young age of the patients may act as a benefic factor and delay the AD. Arterial transposition could be an option in the absence of any venous conduit, if anatomy does not permit the use of prosthetic grafts.
Aneurysmal degeneration of the inflow artery after arteriovenous access for hemodialysis
2014, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Renal transplantation also seems to increase inflow artery aneurysmal degeneration,3 probably due to immunosuppression and corticosteroid therapy (which has already been related to the induction of aneurysms).3,12 However, it rarely led to true aneurysmal degeneration, which is an uncommon and late complication after AVF creation,5,13,14 affecting 4.5% of AVF,6 7–19 years after fistula creation4,6 (in this series, 15.6 years later). Although it is a long-tem enlargement, a rapid increase in aneurysmal diameter is usually described from a few days to months before consultation.4,6
After arteriovenous fistula creation, the arterial flow increase can lead to aneurysmal degeneration, even increased after fistula ligation or renal transplant immunosuppression. The aim of this study is to describe the therapeutic options and outcomes of true aneurysms of the inflow artery after arteriovenous fistula for hemodialysis.
Prospectively collected data of patients with true aneurysmal degeneration of the inflow artery after fistula creation (excluding pseudoaneuryms, anastomotic or infected aneurysms, or surgical complications), surgically repaired between January 2010 and February 2014 (cohort study) have been included. Patient demographics and access characteristics, symptoms, treatment, and follow-up have been reviewed.
12 patients (75% men, median age 63 years) were treated for aneurysmal degeneration of the axillary (1), brachial (6), or radial (5) artery. They had had a previous distal arteriovenous fistula (7 radiocephalic, 3 brachiocephalic, 2 brachiobasilic) created 15.6 years before (range 9.9–28.5) and the majority of them were currently ligated or thrombosed. Most patients were symptomatic (pain [6], distal embolization [1]). They were treated by means of a bypass (using the cephalic [3], basilic [4], or saphenous vein [2]), direct ligature (2), or excision with end-to-end reconstruction (1). No major complications or ischemic symptoms occurred before discharge. After a median follow-up of 8.6 months (3.1–36.5), one patient needed re-operation for new proximal brachial aneurysmal degeneration, and another presented with an asymptomatic post-traumatic thrombosis of the proximal axillary artery and brachial bypass. No other complications, bypass dilatation or ischemic symptoms occurred during follow-up.
Inflow artery aneurysmal degeneration can occur after long-term arteriovenous access. Surgical treatment by autogenous bypass exclusion in most cases (or ligation or end-to-end reconstructions in selected cases) is a safe and effective option.

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Case ReportsLate Occurrence of a Large Brachial Artery Aneurysm following Closure of a Hemodialysis Arteriovenous Fistula

Section snippets

CASE REPORT

DISCUSSION

Eur J Vasc Endovasc Surg

Eur J Vasc Surg

Ann Vasc Surg

J Vasc Surg

The history of an aneurysm of the aorta with some remarks on aneurysms in general

Trans Med Obstet Soc Phys Lond

Case Reports
Late Occurrence of a Large Brachial Artery Aneurysm following Closure of a Hemodialysis Arteriovenous Fistula