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ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 211-214

Vascular access related aneurysms in patients on maintenance hemodialysis


1 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission14-Aug-2019
Date of Acceptance22-Sep-2019
Date of Web Publication17-Oct-2019

Correspondence Address:
Dr. Siva Parvathi Karanam
Assistant Professor, Department of Nephrology, SVIMS, Tirupati, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_84_19

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  Abstract 


Background and Aims: Arterio-venous (AV) access has been considered as an Achilles heel in the management and outcomes of End Stage Renal Disease (ESRD) patients on Maintenance Hemodialysis (MHD). Vascular Access Related Aneurysms (VARA) significantly impact the functional status of the AV access and thus affects the patients' outcomes. Our study was taken up in this context. This study was conducted to decipher the anatomical, functional, imaging, complications and management aspects of VARA.
Methods: A cross-sectional, observational study was done on 429 patients of ESRD on MHD in our institute. The clinical aspects, demographics, imaging aspects were stressed followed by management. Both descriptive and inferential statistics were used and aP value <0.05 was considered as significant.
Results: Total number of study participants were 429. Of them, 48 patients developed AVF aneurysms (11.1%). The mean age of the patients was 52.9 years with a male: female ratio of 34: 14. Majority of them were ESRD due to diabetic nephroathy (62.5%). Morphologically majority of them were saccular (69%) while rest of them were fusiform (31%) None of our patients had downstream stenosis, and thrombus was seen in 5 patients (10.4%), complications secondary to rupture of AVF with hemorrhage, was seen in 6.25% (n = 3).
Conclusions: We found VARA in 11.6% of our MHD population predominantly in men, in their middle age. They were more common in diabetic ESRDS. Aneurysmal rupture was seen in 6.25%. Our study highlights the importance of periodic evaluation for aneurysms and necessary management.

Keywords: Arteriovenous fistula (AVF) complications, maintenance hemodialysis, Vascular access related aneurysms


How to cite this article:
Lokesh P, Karanam SP, Nagaraj R D, Praveen N, Sunnesh A, Sameera N S, Naveen K, Teja, Lakshmi A Y, Rukmangada, Sivakumar V. Vascular access related aneurysms in patients on maintenance hemodialysis. J NTR Univ Health Sci 2019;8:211-4

How to cite this URL:
Lokesh P, Karanam SP, Nagaraj R D, Praveen N, Sunnesh A, Sameera N S, Naveen K, Teja, Lakshmi A Y, Rukmangada, Sivakumar V. Vascular access related aneurysms in patients on maintenance hemodialysis. J NTR Univ Health Sci [serial online] 2019 [cited 2019 Nov 15];8:211-4. Available from: http://www.jdrntruhs.org/text.asp?2019/8/3/211/269493




  Introduction Top


The vascular access is considered as the life line and Achilles heel for a successful Maintenance Hemodialysis (MHD) Program.[1] The ArteriovenousFistula (AVF) is the recommended vascular access for MHD patients as it is associated with long term patency when compared to arteriovenous grafts (AV G) and less number of complications when compared to central venous catheters.[2] However, they are not without complications like primary AVF failures in the short term, aneurysmal dilatation of the access in the long term along with other complications like secondary failures, infections, thrombosis and central vein stenosis.[3]

Vascular access related aneurysms (VARA) is a complication owing to the physiological changes that take place after the creation of AVF, as well as the pathological changes that occur during each dialysis session. The development of aneurysms in AVFS has been explained secondary to patient related factors, procedural trauma related factors, and access related hemodynamic factors which include repeated cannulation, bleeding from cannulation site with hematoma formation infection of AVF and patient related factors like age, presence of diabetes, peripheral vascular disease, hypertension, dyslipidemia, and deposition of abnormal collagen in the vasculature secondary to uremia itself. It is important to know the presence of downstream or upstream stenosis, as it enhances the intra access pressures and promotes vascular access related aneurysms.[4] The reported incidence of aneurysm formation is approximately 5% to over 60% in vascular access.[5],[6]

Basing on the morphology of aneurysms of AVF, Valenti et al. recently proposed a classification system consisting of four types. Types 1 to 3 being true aneurysms and type 4 is pseudo aneurysm. Type 1 is again divided in to two types, type 1a, which involves along the length of the vein, type 1b being post anastomotic. Type 2 aneurysms are more localized and type 3 are classified as complex. False or pseudo aneurysms usually occur at the site of needle puncture or at the site of anastomosis and may be simply a hematoma communicating with the lumen of the access and with time, they may develop a fibrous sac but are devoid of endothelium or vascular wall structure.[4] It is difficult to define true aneurysms because the vein of an AVF typically increases in diameter greater than three-fold to mature enough for needling.).[4] The aneurysms of the AV fistula are usually the result of destruction of the vessel wall and replacement by a biophysically inferior collagenous tissue. Once they are formed, the law of Laplace predicts that there is a tendency to progress spontaneously because wall stress becomes greater with increasing diameter of the aneurysm.[7]

Patients with VARA present with of prolonged bleeding after dialysis, swelling, pain and parasthesia distal to AVF, skin ulceration, infections with impending rupture and rupture with fatal life threatening bleeding.[3] Also the efficiency of dialysis may be compromised if patient has associated thrombus and decreased blood flow despite aneurysmal dilatation and also the most important complication of these fistulas is on the cardiovascular system, with increased cardiac workload and resultant high output cardiac failure given the high flows in these AVF with aneurysmal dilatation.[7] Defining the time for intervention as well as the modality of treatment in these patients is complex, however there are certain conditions which require emergency ligation of AVF which include signs of imminent rupture (skin ulceration/scab or infection). Growth of more than 10% per year on regular monitoring, shiny and atrophic skin over the AVF aneurysm are other indications considered for surgery.[4] The preventive approaches cited to decrease the aneurysms of vascular access include 1. use of appropriate needling techniques like rope ladder technique or button hole technique with blunt needles,[7] and 2. Use of prophylactic doxycycline has a proven benefit to reduce the formation of aneurysms.[8]


  Methods Top


It was an observational study conducted during the period of one year from January 2018 to December 2018. All patients who were undergoing maintenance hemodialysis at our institute were included, and the patients who developed aneurysmal dilatation of vascular access were included for further analysis. The continuous variables were expressed as mean ± standard deviation, whereas categorical variables were expressed as percentages. Student t test was used to test the significance between parameters. SPSS 16 software is used for statistical analysis and a P value < 0.05 was considered statistically significant.


  Results Top


A total of 522 patients were undergoing MHD at our institute during the study period. Among them 429 patients were on a permanent access, out of them 48 patients developed AVF aneurysms (11.1%). The mean age of the patients was 52.9 years with a male: female ratio of 34: 14. Diabetic nephropathy was the cause of end stage renal disease in majority (62.5%) of the patients and rest were of non-diabetic etiology (37.5%).


  Discussion Top


In our study on 429 patients with permanent vascular access as AVF, on MHD, we found 48 patients developed AVF aneurysms (11.1%). None of them occurred in AV Grafts or BrachioBasilic fistula. The mean age of the patients was 52.9 years with a male: female ratio of 34:14. Diabetic nephropathy was the cause of endstage renal disease in majority (62.5%) of the patients, morphologically majority of them were saccular (69%) while rest of them were fusiform (31%) [Figure 1]a, [Figure 1]b [Table 1]. Most of the VARA were found with RC AVF in comparision to BC AVF [Table 2]. Basing on Valenti et al. classification, majority of the VARA belonging to type 1a [Table 3]. Most of our patients were detected to have aneurysms on routine clinical examination as a part of vascular access surveillance and subsequently all of them underwent thorough radiological evaluation with ultrasound Doppler color flow to characterize the aneurysm site, asses its flow, rule out downstream stenosis and associated thrombus adherent to the wall. None of our patients had downstream stenosis, and thrombus was seen in 5 patients (10.4%).
Figure 1: (a) Showing fusiform aneurysm. (b) showing saccular aneurysm

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Table 1: Demographic And Vascular Access Related Details Of Patients With AVF Aneurysms

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Table 2: Showing Association Of Aneurysms In Different Types Of AVFS

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Table 3: Classification Of Aneurysms Based On Classification Proposed By Valeti et al.

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On sonographic evaluation, the parameters studied were tabulated [Table 4]. We did not find any statistically significant difference in the parameters between diabetic and nondiabetic CKD patients [Table 5]. However there was statistically significant difference noted between types of AVF, RC AVF and BCAVF in peak systolic velocity of feeding artery, aneurysmal diameter were more in BC AVF in comparison to RC AVF. Also the aneurysms in BC AVF were more closer to skin surface [Table 6]. Despite regular patient education on the expected complications and regular follow-up, three of them presented in emergency for ligation of fistula secondary to rupture of AVF with hemorrhage ([Figure 2] of ruptured avf5), while rest of them were under regular surveillance.
Table 4: Radiological Parameters Of AVF Aneurysms

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Table 5: Radiological Parameters Of Patients With Vara, Difference Between Diabetics And Non Diabetics

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Table 6: Radiological Parameters Difference Between RCA AVF And BC AVF

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Figure 2: Figure 2 showing histopathology of a ruptured aneurysm with thinned out tunica intima and replacement of vessel wall with fibrous tissue

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  Conclusion Top


In our study, we found that aneurysms of vascular access were more common in men, in the middle age, in diabetics with an average duration of dialysis of over 4 years. The aneurysms were more common in radio cephalic AVF and morphologically majority of them belonging to Valenti type 1a. Regular patient education on the AVF care including periodic ultrasound with Doppler monitoring of AVF need implementation in the programme to reduce complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Riella MC, Roy-Chaudhury P. Vascular access in haemodialysis: Strengthening the Achilles' heel. Nat Rev Nephrol 2013;9:348-57.  Back to cited text no. 1
    
2.
Schwab S, Besarab A, Beathard G, Brouwer D, Etheredge E, Hartigan M, et al. NKF-DOQI clinical practice guidelines for vascular access. Am J Kidney Dis 1997;30:S150-91.  Back to cited text no. 2
    
3.
Zibari GB, Rohr MS, Landreneau MD, Bridges RM, DeVault GA, Petty FH, et al. Complications from permanent hemodialysis vascular access. Surgery 1988;104:681-6.  Back to cited text no. 3
    
4.
Mudoni A, Cornacchiari M, Gallieni M, Guastoni C, McGrogan D, Logias F, et al. Aneurysms and pseudoaneurysms in dialysis access. Clin Kidney J 2015;8:363-7.  Back to cited text no. 4
    
5.
Pasklinsky G, Meisner RJ, Labropoulos N, Leon L, Gasparis AP, Landau D, et al. Management of true aneurysms of hemodialysis access fistulas. J Vasc Surg 2011;53:1291-7.  Back to cited text no. 5
    
6.
Valenti D, Mistry H, Stephenson M. A novel classification system for autogenous arteriovenous fistula aneurysms in renal access patients. Vasc Endovascular Surg 2014;48:491-6.  Back to cited text no. 6
    
7.
Konner K, Nonnast-Daniel B, Ritz E. The arteriovenous fistula. J Am Soc Nephrol 2003;14:1669-80.  Back to cited text no. 7
    
8.
Diskin C, Stokes TJ, Dansby LM, Radcliff L, Carter TB. Doxycycline may reduce the incidence of aneurysms in haemodialysis vascular accesses. Nephrol Dial Transplant 2005;20:959-61.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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