Abstract
A pseudoaneurysm or a false aneurysm is the consequence of a persistent blood leak caused generally by iatrogenic rupture of a vessel wall. In hemodialysis fistula, pseudoaneurysm results from repeated puncturing of the vein at the same site. Surgery and endovascular treatment stay widely used as the treatment of pseudoaneurysm compared to the ultrasound-guided manual compression (UGMC). UGMC is a non-invasive and effective procedure which could be attempted before invasive procedures. We reported two cases of successful treatment of pseudoaneurysm by ultrasound-guided compression. A total thrombosed cavity has been obtained and fistulas could be cannulated in the next session.
Keywords: Hemodialysis arteriovenous fistula, Pseudoaneurysm cavity, Pulsatile mass, Ultrasound-guided manual compression
Sommario
Lo pseudoadeurisma o falso aneurisma è la conseguenza di una perdita di sangue persistente causata generalmente dalla rottura iatrogena di una parete di un vaso. Nella fistola di emodialisi, lo pseudoaneurisma deriva da ripetuta foratura della vena nello stesso sito. La chirurgia e il trattamento endovascolare rimangono ampiamente usati per il trattamento di pseudoaneurisma rispetto alla compressione manuale guidata ad ultrasuoni (UGMC). UGMC è una procedura non invasiva ed efficace che potrebbe essere tentata prima delle procedure invasive. Presentiamo di seguito due casi di trattamento efficace di pseudoaneurisma mediante compressione guidata ad ultrasuoni. È stata ottenuta una totale trombosi della cavità trombosa e le fistole possono essere incannulate nella sessione successiva.
Introduction
A pseudoaneurysm or a false aneurysm is the consequence of a persistent blood leak caused generally by iatrogenic rupture of a vessel wall. The blood leak creates a new cavity delimited by surrounding tissues and allows blood flow to remain in continuity between this cavity and the vessel.
A pseudoaneurysm or a false aneurysm should be differentiated from an aneurysm or a true aneurysm. A true aneurysm is a vessel dilatation without blood leaking.
In hemodialysis fistula, pseudoaneurysm generally results from repeated puncturing of the vein at the same site, leading to a bulging anatomical defect in the vein area. Serious complications can occur like fistula thrombosis or skin rupture. Surgery and endovascular treatment stay widely used as the treatment of pseudoaneurysm compared to ultrasound-guided manual compression (UGMC).
In femoral artery pseudoaneurysm, UGMC is a well-accepted treatment but stays rarely reported in hemodialysis arteriovenous fistula.
We reported two cases of a successful pseudoaneurysm treatment by ultrasound-guided compression.
Case 1
A 68-year-old woman with end-stage renal disease undergoing hemodialysis with a right transposed brachiobasilic arteriovenous fistula (AVF) presented just after her hemodialysis session a new pulsatile and painful mass, localized in cannulation sites. Hemodialysis needle used was a 16 gauge and the cannulation technique was site rotation. Hemostasis after needles removal has been obtained after 6 min of manual compression.
Doppler ultrasound has been performed showing a large pseudoaneurysm over the vein measuring 4 × 2.8 cm. Color mode confirmed blood flow continuity between the pseudoaneurysm cavity and the outflow vein through a tear in the vein wall (Fig. 2). An ultrasound-guided manual compression (UGMC) was attempted to stop blood flow into the pseudoaneurysm cavity. The compression has been done manually over the mass and ultrasonography was used to ensure reduction of blood circulation in the cavity (Fig. 1). After 30 min of manual compression, we have had a total thrombosed pseudoaneurysm cavity (Fig. 3). The brachial flow rate was 1150 mil/min and no recurrence was noted in the following days.
Fig. 2.
Pseudoaneurysm cavity connected to the outflow vein through a rupture in the vein wall
Fig. 1.
Ultrasound-guided manual compression technique
Fig. 3.
Total thrombosed pseudoaneurysm cavity after ultrasound-guided manual compression
Case 2
A 65-year-old woman treated by hemodialysis during 5 years with a left transposed brachiobasilic AVF presented a new bulging anatomical defect in the vein area. Hemodialysis needle used was a 16 gauge and the cannulation technique was site rotation. Hemostasis after needles removal could not be obtained by manual compression and suture at the needle site was necessary to stop blood loss during its session 2 days before.
Doppler ultrasound showed a pseudoaneurysm (2.5 × 0.99 cm) connected to the outflow vein through a large tear in the vein wall. Blood flow continuity in systole phase and diastole phase has been confirmed by color Doppler.
An ultrasound-guided manual compression (UGMC) was attempted to occlude the pseudoaneurysm cavity. After 20 min of manual compression, we have had a total thrombosed pseudoaneurysm cavity. The brachial flow rate was unchanged and no recurrence was noted in the following days.
Discussion
Pseudoaneurysm is a well-known complication in endovascular femoral artery procedures with a reported frequency between 0.05 and 0.55% [1, 2]. This rate increases between 7 and 8% if patients are under anticoagulant treatment [2, 3]. Different treatments were reported: Korkmaz and al reported a stethoscope-guided compression with 89.6% success rate [4]. Schneider C. et al reported a prospective study of 274 patients who received ultrasound thrombin injection as a first-line treatment for iatrogenic femoral artery pseudoaneurysms following cardiac diagnostic with a successful rate of 97% [5]. Te-Li Huang reported 8 years experience of ultrasound-guided compression repair of peripheral artery pseudoaneurysm and successful thrombosis was achieved in 90.5% patients [6]. In long term endovascular procedures follow-up, contrast enhanced ultrasound (CEUS) could rule out with a very similar results complications like pseudoaneurysm compared to the CT angiography [7–9]. Pseudoaneurysm in hemodialysis AVF is frequently seen in graft fistula rarely in native arteriovenous fistula. Its incidence rates range between 2 and 10% in grafts [10, 11]. Delamore and al [12] analyzed 52 surgically excised PTFE grafts and reported that histological evaluation revealed a perigaft fibrous tissue capsule directly above the areas where the graft was punctured.
In native AVF, few cases have been reported; Najibi et al. reported two cases of AVF pseudoaneurysms successfully treated with covered stents [13]. Reichle et al. [14] describe one forearm AVF pseudoaneurysm’s successfully treated using UGC; the digital compression was done directly over the connection between the cavity and the outflow vein localized by the ultrasonography. Witz et al. [15] reported three cases of AVF pseudoaneurysm’s treated successfully by UGC using manual compression directly over the pseudoaneurysm cavity identifiable by the ultrasonography. The time needed to occlude the pseudoaneurysm ranged from 20 to 45 min. The fistula was preserved for the three patients. Ultrasound-guided manual compression of venous pseudoaneurysms of upper arm dialysis AVF is a safe, effective, non-invasive treatment that should be attempted before endovascular or open surgical alternatives [15–17]. In this paper, the author reports 2 cases of venous pseudoaneurysms in a native brachiobasilic transposed AVF that has been repaired with manual compression guided with US without any variation of brachial flow rate.
Conclusion
Ultrasound AVF monitoring allows the diagnostic of different forms of venous pseudoaneurysm, which becomes more important when the pseudoaneurysm is deep and not visible.
Ultrasound-guided manual compression of venous pseudoaneurysms of upper arm dialysis AVF is a safe, effective, non-invasive treatment that should be attempted before endovascular or open surgical alternatives.
Compliance with ethical standards
Conflict of interest
Mohamed amine Rahil declares that he has no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent
Informed consent was obtained from all individual participants included in the study.
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