M Acipayam, S Canbaz, E Duran
arteriovenous access graft, pseudoaneurysm
M Acipayam, S Canbaz, E Duran. The Pseudoaneurysm At The Graftotomy Site In Arterio-Venous Access Graft. The Internet Journal of Thoracic and Cardiovascular Surgery. 2002 Volume 6 Number 1.
Backround: Thrombosis and pseudoaneursym are the most important complications of synthetic hemodialysis grafts. A rare case with a pseudoaneurysm of arterio-venous access hemodialysis graft which developed at the site of graftotomy is presented. Pseudoaneurysm formation usually occurs at the anastomotic line. But in this case, pseudoaneurysm was seen at the site of graftotomy.
Methods: The patient was taken to surgery. The ruptured pseudoaneurysm and synthetic graft were excised.
Results: Postoperative condition was uneventfull.
Conclusion: Thrombolytic therapy can decrease surgical complications in thrombosed synthetic hemodialysis grafts.
Hemodialysis is one of the methods used in the palliative treatment of the patients with end-stage chronic renal failure (1). This treatment method is requires arterio-venous (a-v) fistulas in the majority of cases. In the patients with inadequate or thrombozed veins due to repeatedly punctures, construction of a-v fistula with a synthetic graft is accepted as an alternative method (2,3).
Thrombosis, infection, pseudoaneurysm, steal syndrome, stenosis, venous congestion, seroma formation, hand ischemia, hematoma may develop while using a-v access grafts (4,5). Pseudoaneurysms of synthetic grafts usually occur at the site of anastomosis with the patient's artery. We could'n find any case in literature with a pseudoaneurysm occuring at the graftotomy site.
A 45-year-old woman who had undergone repeated a-v fistulas operations in our institute is presented. Because of unsuitable veins of upper extremities and formation of bilateral subclavian vein thrombosis, a loop a-v access graft (Venaflo, ePTFE vascular graft; IMPRA, Inc.USA) was inserted between the right femoral artery and the rigth femoral vein. Afterwards, the graft thrombosed and the patient needed 3 open thrombectomy operations. The patient was spontaneously referred to the emergency service for swelling of the leg. In the physical examination, a 8 cm diametered pulsatile mass which eroded the skin was detected at the graft site. Dupplex ultrasound and a-v graft angiography were scheduled, but before these examinations massive bleeding following severe coughing occurred. The patient was taken immediately to the operation room. Under general anesthesia, the femoral artery and vein were explorated with a groin incision. A ruptured pseudoaneurysm was seen at the thrombectomy site of graft. During excision of the pseudoaneurysm, ventricular tachicardia developed and dc cardioversion was performed. After ligation of the ends, the graft was excised. Due to unstability of the patient, the operation was terminated. A permanent dialysis cathater was inserted via right internal juguler vein. The postoperative period was uneventfull and the paient was discharged in good condition.
The most common complications of a-v access grafts are stenosis and thrombosis (6).
With repeated punctures, the graft wall may become thin and an aneurysm may develop. Aneurysm formation occurs as a complication in 5-8 % of a-v fistulas (7). This complication may play a role as a source of embolism and thrombosis. The skin over the aneurysm may become thin and infection and haemorrhage may develop. The aneurysm may cause a delay of hemodialysis in some patients (7). An aneursym is mainly develops by using suboptimal dialysis technique in the patients with prosthetic grafts or autograft veins. The development of aneurysmatic degeneration can be delayed by changing the needle puncture points (7). Surgical replacement of PTFE graft or autogenous vein has been the traditional repairment of pseudoaneurysm (8). Repair of the aneurysm is not the preferred method because the graft is frequently damaged and needs to be changed.
Prior grafts are strongly adhered to the surrounding tissue. For this reason, removal of the graft is rarely needed and is not adviced (7). Remove of the graft usually needs the excision of the surrounding tissue, and it results excessive scar formation and haemorrhage. In most cases, a new graft is put in place near the prior grafts. It is reported that the pseudoaneursyms are usually seen at the site of the anastomosis with the patient's artery. However, in our case, we observed the ruptured pseudoaneursym at the thrombectomy site. Graft resection and a new graft interposition had been planned. But it couldn't performed due to deterioration of the patient's condition and development of ventricular tachicardia. For this reason, the graft was excised and the operation was rapidly finished. In graft thrombosis, thrombolytic therapy before open thrombectomy is recommended to decrease the surgical complications (9). Endovascular repair is also an effective way as an alternative method for graft pseudoaneurysm (10).
Dr. Suat CANBAZ, Department of Cardiovascular Surgery, Medical Faculty, Trakya University, 22030 Edirne, Turkey Phone: +90 284 235 76 56 Fax: +90 284 235 06 65 e mail: firstname.lastname@example.org