Letter to the Editor
True brachial artery aneurysm following vascular access for haemodialysis in renal transplant patient. Two case reports
Aneurisma humeral verdadero en relación con acceso vascular en paciente trasplantado renal: a propósito de 2 casos clínicos
Carlota Fernández Prendes
, Ahmad Amer Zanabili Al-Sibbai, Mario González Gay, Jose Antonio Carreño Morrondo, Manuel Alonso Pérez
Corresponding author
Servicio de Angiología y Cirugía Vascular, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Two case reports" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1485 "Ancho" => 1447 "Tamanyo" => 208937 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Arteriografía selectiva: A) Arterial humeral con un diámetro máximo de 6<span class="elsevierStyleHsp" style=""></span>cm. 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Two case reports" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "96" "paginaFinal" => "98" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carlota Fernández Prendes, Ahmad Amer Zanabili Al-Sibbai, Mario González Gay, Jose Antonio Carreño Morrondo, Manuel Alonso Pérez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Carlota" "apellidos" => "Fernández Prendes" "email" => array:1 [ 0 => "carlota.f.prendes@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Ahmad Amer" "apellidos" => "Zanabili Al-Sibbai" ] 2 => array:2 [ "nombre" => "Mario" "apellidos" => "González Gay" ] 3 => array:2 [ "nombre" => "Jose Antonio" "apellidos" => "Carreño Morrondo" ] 4 => array:2 [ "nombre" => "Manuel" "apellidos" => "Alonso Pérez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Angiología y Cirugía Vascular, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aneurisma humeral verdadero en relación con acceso vascular en paciente trasplantado renal: a propósito de 2 casos clínicos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1485 "Ancho" => 1447 "Tamanyo" => 208937 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Selective arteriography: (A) humeral artery with a maximum diameter of 6<span class="elsevierStyleHsp" style=""></span>cm. (B) Three-dimensional reconstruction of computerised angiotomography, showing aneurysmal dilatation of the humeral artery, with a maximum diameter of 4.5<span class="elsevierStyleHsp" style=""></span>cm and a single outlet through the ulnar artery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Humeral artery aneurysms (HAA) are an uncommon condition, usually secondary to trauma, infection or connective tissue disease.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> They have also been described in the context of arteriovenous fistulas (AVF) for haemodialysis; the majority are anastomotic or venous pseudoaneurysms, with few true degenerative arterial aneurysms. We present two cases of true HAA:</p><p id="par0010" class="elsevierStylePara elsevierViewall">Case one is a 44-year-old male with rapidly progressive glomerulonephritis who started haemodialysis at age 20 (1978) through a left radiocephalic AVF. During the course of his illness he received two kidney transplants. In 1996 a new radiocephalic AVF was performed on the contralateral arm due to thrombosis of the previous fistula. In 2003, an asymptomatic true HAA of 6<span class="elsevierStyleHsp" style=""></span>cm diameter was detected and confirmed by arteriography. Aneurysmal resection was performed with interposition of the inverted internal saphenous vein extracted from the left lower extremity. Two years later, a 4.5<span class="elsevierStyleHsp" style=""></span>cm aneurysmal dilatation of the venous graft was detected (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and it was repaired by PTFE prosthesis interposition. During the follow-up, no other complications were detected, with exitus in 2009 from metastatic clear-cell renal cell carcinoma.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Case two is a 55-year-old male, former smoker and with uncontrolled arterial hypertension, who started haemodialysis at age 40 (2000) through a left radiocephalic AVF due to malignant nephroangiosclerosis, receiving a kidney transplant in 2001. He had a past medical history of popliteal aneurysm in the right lower limb, operated with a femoropopliteal bypass with inverted saphenous vein, which required supracondylar amputation due to acute thrombosis. The AVF was closed in 2007 due to vein aneurysmal degeneration. In 2015, an asymptomatic true HAA of 4.5<span class="elsevierStyleHsp" style=""></span>cm in diameter was documented by Doppler ultrasound and confirmed by computerised axial angiotomography (CT angiography) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Aneurysmal resection and inverted homolateral basal vein interposition were performed. At the 6-month follow-up, the bypass remained permeable and free of complications.</p><p id="par0020" class="elsevierStylePara elsevierViewall">HAAs have been described in the context of AVF for haemodialysis, although most are anastomotic or venous pseudoaneurysms. True degenerative aneurysms are very rare, with an estimated incidence of 0.17%.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> True HAAs are most often associated with radiocephalic AVFs (60%), followed by brachiocephalic AVFs (36%), and generally appear 7–19 years after it placement.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Unlike aortic, femoral, and popliteal aneurysms, HAAs do not appear to be associated with synchronous aneurysms in other locations.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> All of this suggests a etiopathogenic origin different from other true degenerative aneurysms.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Several mechanisms have been described that cause a significant increase in arterial diameter after the creation of an AFV; an increase in intra-arterial blood flow generates fissures in the elastic fibres in the internal lamina creating a predisposition to aneurysmal degeneration; in addition, an increase in the wall tension increases the release of endothelial factors such as nitric oxide.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4,5</span></a> These mechanisms are neither prevented nor avoided by closure or thrombosis of the AVF.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Kidney transplantation has been associated with aneurysmal arterial progression proximal to the AVF, while treatment with steroids and immunosuppressants has also been associated with an increased incidence of HAA.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,6,7</span></a> The two cases presented here were kidney transplant patients who received immunosuppressive therapy for more than 10 years and developed HAA 15 and 25 years after creation of the AVF, respectively.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Their most frequent clinical manifestation is in the form of an asymptomatic pulsatile mass, although they can cause pain and paresthesias due to local compression. Distal embolisation has been observed in 28–30% of cases, while the other ischaemic presentations are unusual and rupture is extremely rare.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,8,9</span></a> The initial diagnostic test is colour Doppler ultrasonography, although CT angiography is the most commonly used technique for surgical planning.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Due to their low frequency, therapeutic indications are usually based on those accepted for popliteal aneurysms. Surgery is generally indicated for asymptomatic HAAs measuring 3<span class="elsevierStyleHsp" style=""></span>cm or more. For those measuring 2–3<span class="elsevierStyleHsp" style=""></span>cm, surgery is recommended if compressive symptoms or distal embolisation are present.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> First-line treatment is usually aneurysmal resection, maintaining arterial continuity by direct suture if possible. If revascularisation is required, the use of autologous grafts is preferred; if these are unavailable, prosthetic grafts or allografts would be used.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,8–10</span></a> In a systematic review published in 2015, with 12 selectable articles and 23 cases described in total, the mean permeability was 12 months (1–38 months) after autografting and 6 months (1–48 months) after PTFE interposition.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although systematic monitoring by ultrasound in patients with an AVF is not recommended, probably because it is not cost-effective; however it would be reasonable to perform a physical examination of the AVF at follow-up visits or at haemodialysis sessions.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> If aneurysmal degeneration is suspected it would be advisable to request a ultrasound to make early diagnosis and avoid possible thromboembolic and/or compressive complications.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Prendes C, Zanabili Al-Sibbai AA, González Gay M, Carreño Morrondo JA, Alonso Pérez M. Aneurisma humeral verdadero en relación con acceso vascular en paciente trasplantado renal: a propósito de 2 casos clínicos. Nefrologia. 2017;37:96–98.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1485 "Ancho" => 1447 "Tamanyo" => 208937 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Selective arteriography: (A) humeral artery with a maximum diameter of 6<span class="elsevierStyleHsp" style=""></span>cm. (B) Three-dimensional reconstruction of computerised angiotomography, showing aneurysmal dilatation of the humeral artery, with a maximum diameter of 4.5<span class="elsevierStyleHsp" style=""></span>cm and a single outlet through the ulnar artery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brachial arteriomegaly and true aneurysmal degeneration: case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.D. Schunn" 1 => "T.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 48 | 41 | 89 |
| 2024 September | 70 | 30 | 100 |
| 2024 August | 65 | 62 | 127 |
| 2024 July | 59 | 31 | 90 |
| 2024 June | 61 | 29 | 90 |
| 2024 May | 69 | 32 | 101 |
| 2024 April | 58 | 31 | 89 |
| 2024 March | 40 | 34 | 74 |
| 2024 February | 45 | 36 | 81 |
| 2024 January | 43 | 25 | 68 |
| 2023 December | 35 | 34 | 69 |
| 2023 November | 48 | 30 | 78 |
| 2023 October | 80 | 30 | 110 |
| 2023 September | 81 | 31 | 112 |
| 2023 August | 101 | 21 | 122 |
| 2023 July | 78 | 23 | 101 |
| 2023 June | 55 | 20 | 75 |
| 2023 May | 88 | 27 | 115 |
| 2023 April | 44 | 14 | 58 |
| 2023 March | 69 | 17 | 86 |
| 2023 February | 53 | 22 | 75 |
| 2023 January | 47 | 18 | 65 |
| 2022 December | 66 | 29 | 95 |
| 2022 November | 75 | 24 | 99 |
| 2022 October | 42 | 24 | 66 |
| 2022 September | 59 | 37 | 96 |
| 2022 August | 59 | 38 | 97 |
| 2022 July | 56 | 43 | 99 |
| 2022 June | 63 | 35 | 98 |
| 2022 May | 73 | 34 | 107 |
| 2022 April | 58 | 55 | 113 |
| 2022 March | 55 | 52 | 107 |
| 2022 February | 49 | 54 | 103 |
| 2022 January | 59 | 47 | 106 |
| 2021 December | 90 | 41 | 131 |
| 2021 November | 53 | 33 | 86 |
| 2021 October | 58 | 42 | 100 |
| 2021 September | 53 | 38 | 91 |
| 2021 August | 49 | 49 | 98 |
| 2021 July | 39 | 38 | 77 |
| 2021 June | 78 | 31 | 109 |
| 2021 May | 68 | 46 | 114 |
| 2021 April | 146 | 84 | 230 |
| 2021 March | 50 | 47 | 97 |
| 2021 February | 54 | 19 | 73 |
| 2021 January | 54 | 15 | 69 |
| 2020 December | 28 | 22 | 50 |
| 2020 November | 52 | 16 | 68 |
| 2020 October | 28 | 27 | 55 |
| 2020 September | 23 | 14 | 37 |
| 2020 August | 47 | 15 | 62 |
| 2020 July | 56 | 16 | 72 |
| 2020 June | 30 | 21 | 51 |
| 2020 May | 55 | 16 | 71 |
| 2020 April | 41 | 14 | 55 |
| 2020 March | 48 | 13 | 61 |
| 2020 February | 49 | 24 | 73 |
| 2020 January | 62 | 20 | 82 |
| 2019 December | 63 | 30 | 93 |
| 2019 November | 31 | 32 | 63 |
| 2019 October | 32 | 15 | 47 |
| 2019 September | 45 | 25 | 70 |
| 2019 August | 28 | 15 | 43 |
| 2019 July | 42 | 25 | 67 |
| 2019 June | 53 | 17 | 70 |
| 2019 May | 36 | 21 | 57 |
| 2019 April | 73 | 26 | 99 |
| 2019 March | 58 | 26 | 84 |
| 2019 February | 30 | 17 | 47 |
| 2019 January | 48 | 25 | 73 |
| 2018 December | 119 | 43 | 162 |
| 2018 November | 183 | 28 | 211 |
| 2018 October | 204 | 25 | 229 |
| 2018 September | 106 | 20 | 126 |
| 2018 August | 53 | 17 | 70 |
| 2018 July | 78 | 17 | 95 |
| 2018 June | 87 | 15 | 102 |
| 2018 May | 98 | 12 | 110 |
| 2018 April | 128 | 15 | 143 |
| 2018 March | 130 | 18 | 148 |
| 2018 February | 158 | 11 | 169 |
| 2018 January | 123 | 5 | 128 |
| 2017 December | 121 | 7 | 128 |
| 2017 November | 64 | 15 | 79 |
| 2017 October | 37 | 6 | 43 |
| 2017 September | 58 | 5 | 63 |
| 2017 August | 66 | 11 | 77 |
| 2017 July | 58 | 9 | 67 |
| 2017 June | 53 | 5 | 58 |
| 2017 May | 75 | 10 | 85 |
| 2017 April | 43 | 6 | 49 |
| 2017 March | 39 | 6 | 45 |
| 2017 February | 11 | 1 | 12 |
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