Partial aneurysmectomy for salvage of autogenous arteriovenous fistula with complicated venous aneurysms

Ahmed Hossny
Journal of Vascular Surgery 2014, 59 (4): 1073-7

OBJECTIVE: One complication of autogenous arteriovenous fistula (AVF) for hemodialysis is the formation of a venous aneurysm (VA). The treatment of massive aneurysmal AVF generally involves ligation or resection with the use of prosthetic interposition. Partial aneurysmectomy, with or without reduction venoplasty, has been suggested to treat such a complicated AVF to maintain an all-autogenous access. The purpose of this study was to describe these procedures and examine their outcomes.

METHODS: From January 2008 to May 2012, 14 patients (64% males) with complicated VAs were treated by partial aneurysmectomy with reduction venoplasty for a diffusely dilated venous segment. Patients with an infected aneurysm or central vein stenosis were not included. The surgical technique and the postoperative outcome were described.

RESULTS: Patients were a mean age of 37.2 ± 12.2 years. Twenty-five aneurysms and four diffusely dilated segments (7, 10, 15, and 21 cm in length) were treated. Four patients (29%) presented with one aneurysm, nine (64%) with two aneurysms, and one (7%) with three aneurysms. The main clinical indications for intervention were skin necrosis and erosion with imminent danger of bleeding in nine (64%), stenosis related to aneurysm in one (7%), and high flow associated with multiple aneurysms or massive diffuse venous dilatation in four (29%). The AVFs were a mean age of 42.4 ± 8.8 months and the VAs were a mean age of 16.2 ± 4.2 months at the time of partial aneurysmectomy. The mean aneurysm diameter was 5.3 ± 1.6 cm. The procedures were successful in all patients. The mean operative time was 180.3 ± 51.5 minutes (range, 90-245 minutes), and the mean hospital stay was 2.5 ± 1.2 days. In five patients, a sufficient usable portion of the AVF remained for cannulation and was punctured the day after the procedure; in the remaining nine patients, a tunneled hemodialysis catheter was inserted. The AVFs remained patent, without recurrent aneurysms, and were used continuously for dialysis throughout the follow-up periods, which were a mean of 30.4 ± 14.4 months (range, 6-48 months). Two patients with functioning AVFs died of causes that were not related to the aneurysmectomy procedure.

CONCLUSIONS: Partial aneurysmectomy is a simple and effective intervention for managing aneurysm-associated complications. It offers the ability to maintain the benefits of an autogenous access while conserving future dialysis sites. Partial aneurysmectomy is recommended as a first-line choice for managing aneurysm-associated complications.

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