Brachial artery aneurysms following brachio-cephalic AV fistula ligation.

PURPOSE: Peripheral artery aneurysms proximal to a long-standing arteriovenous (AV) fistula can be a serious complication. It is important to be aware of this and manage it appropriately.

METHODS: Vascular access nurses input all data regarding patients undergoing dialysis access procedures into a securely held database prospectively. This was retrospectively reviewed to identify cases of brachial artery aneurysms over the last 3 years.

RESULTS: In Morriston Hospital, around 200 forearm and arm AV fistulas are performed annually for vascular access in renal dialysis patients. Of these, approximately 15 (7.5%) are ligated. Three patients who had developed brachial artery aneurysms following AV fistula ligation were identified. All 3 patients had developed brachial artery aneurysms following ligation of a long-standing brachio-cephalic AV fistula. Two patients presented with pain and a pulsatile mass in the arm, and one presented with pins and needles and discoloration of fingertips. Two were managed with resection of the aneurysm and reconstruction with a reversed long saphenous vein interposition graft, the third simply required ligation of a feeding arterial branch.

CONCLUSIONS: True aneurysm formation proximal to an AV fistula that has been ligated is a rare complication. There are several reasons for why these aneurysms develop in such patients, the most plausible one being the increase in blood flow and resistance following ligation of the AV fistula. Of note, all the patients in this study were on immunosuppressive therapy following successful renal transplantation. Vigilance by the vascular access team and nephrologists is paramount to identify those patients who may warrant further evaluation and investigation by the vascular surgeon.