Aneurysmal Degeneration of the Brachial Artery after Vascular Access Creation: Surgical Treatment Results

Abstract

True peripheral artery aneurysms proximal to a longstanding arteriovenous fistula is a well-recognized complication. Late aneurysmal degeneration is rare. This study analyzed the characteristics, therapeutic options, and outcomes of true donor brachial artery aneurysms (DBAA) after arteriovenous fistula (AVF) for hemodialysis. We retrospectively collected the data of patients with DBAA after AVF creation, surgically repaired between January 2001 and September 2015. We excluded patients with pseudoaneurysms, anastomotic aneurysms, and infected aneurysms. We recorded patient's demographics, type of access, aneurysm characteristics, symptoms, treatment, and follow-up. Ten patients were treated for aneurysmal degeneration of the brachial artery. Average aneurysm diameter was 37.5 mm. All cases had, at least, one previous distal AVF, ligated or thrombosed, at the time of diagnosis. The first access was created in mean 137 months before the diagnosis of DBAA. Nine patients had previous medical history of renal transplant and were under immunosuppressive therapy. All patients were symptomatic at the time of diagnosis. In all cases, the treatment was aneurysmectomy followed by interposition bypass. One patient developed a postoperative hematoma with the need of surgical drainage. At 50 months of follow-up, one patient was submitted to percutaneous angioplasty due to an anastomotic stenosis. No other complications occurred during the entire follow-up period (mean: 69 months). The pathogenesis underlying DBAA remains unclear. Increased blood flow after AVF creation, immunosuppressive therapy, and ligation/thrombosis of the AVF may contribute to aneurysm formation. Surgical treatment by aneurysmectomy and bypass, with autogenous conducts, is a safe and effective option.

Axillary artery aneurysm associated with Arteriovenous malformations of the upper extremity: A case report

“…A well-established example of aneurysms secondary to altered hemodynamics is the development of axillary and brachial aneurysms in patients with AVFs. Teixeira et al [ 16 ] reported 10 patients with brachial artery aneurysms at a mean of 137 months after AVF construction, all of which were treated with aneurysmectomy and venous or prosthetic interposition grafts. Aneurysm development does not appear to be prevented by AVF ligation or thrombosis.…”

Giant Brachial Aneurysm after Arteriovenous Fistula Ligation: A Review of the Different Surgical Approaches

“…The history of aneurysmal brachial formation after AVF ligation is still unclear. Teixeira et al [5] hypothesize an upregulation of vasodilator agents, degradation of elastic fibers and amounts of calcium and phosphate deposition due to dialysis, activation of a proinflammatory process in immunosuppression and corticosteroid long-term therapy, and increased resistance of the vessel wall after ligation of the AVF. Others hypothesize that arterial flow in AVF produces an increase in wall stress and a decrease in wall thickness [6].…”

“…We preferred an open surgical repair approach with aneurysmectomy and interposition of the GSV, which has been demonstrated to be the treatment of choice in terms of good patency and perioperative morbidity [2, 5, 6, 9-15] as well as reduction of infection in patients treated with immunosuppressive therapy [16]. Several groups have described the validity of the GSV as a graft, with excellent results in terms of patency and absence of complications after intervention [2, 5, 6, 9-15]. One case of arteriomegaly proximal to the GSV has been described and was managed with DUS surveillance [17].…”

“…Other authors used the cephalic or basilic ipsilateral vein, with the aim to reduce incisions and, therefore, the duration of the procedure with consequent lower morbidity [18], and to preserve leg veins for future procedures in the arms or other vascular reconstructions [5, 19-21]. One aneurysmal degeneration was described after aneurysmectomy and interposition of basilic vein, which was treated with interposition of another ipsilateral arm basilic vein, and one posttraumatic thrombosis that remained untreated due to absence of symptoms [22].…”

“…When the GSV has to be preserved in patients with cardiovascular risk factors or when it is not suitable as a conduit in chronic venous insufficiency or when other veins are unavailable, a PTFE graft can be used. Several authors used PTFE grafts and showed that a prosthetic graft was a valid alternative; in their individual cases the autologous veins were unavailable [2, 5, 12, 22-25]. No complication were described after PTFE grafts.…”