Endovascular rescue of a prosthetic arteriovenous fistula with multiple pseudoaneurysms in a patient with no other vascular access options
Rescate endovascular de fístula arteriovenosa protésica con múltiples pseudoaneurismas en una paciente con agotamiento de accesos
Martín Rabellinoa, Guillermo Rosa-Diezb, Esteban Mendaroa, Soledad Cruceleguib, Ricardo Posatinic, Ricardo García-Mónacoa
a Servicio de Angiografía y Terapia Endovascular, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina,
b Servicio de Nefrología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina,
c Servicio de Cirugía Cardiovascular, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina,
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however, in recent years, several working groups have incorporated endovascular treatment using the placement of covered stents to exclude this type of lesion.<span class="elsevierStyleSup">2,3</span> Thrombin is not widely used as an embolising agent during the treatment of these lesions, with only a few reports of cases in which this type of treatment has been associated with a stent graft.<span class="elsevierStyleSup">4,5</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case report</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Here we present the case of a 46-year-old patient with chronic renal failure, on trimestral haemodialysis for 23 years secondary to obstructive uropathy, with a left femoral loop (21 months of use) with occluded iliac venous drainage that produced oedema in the leg and three pseudoaneurysms in the therapeutic range. One of these was actively bleeding. The three pseudoaneurysms and occlusion of the left primitive iliac vein were treated using endovascular methods under local anaesthesia. The actively bleeding pseudoaneurysm was excluded with a covered stent, and the other two were percutaneously embolised using balloon-assisted thrombin injections in order to avoid thrombosis in the prosthesis. The iliac venous axis was recanalised and treated with angioplasty balloons; in the final angiographic controls, we observed no pseudoaneurysms, with patency of the prosthesis, iliac venous drainage, no signs of collateral circulation, and without having produced any complications.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Deterioration of the prosthetic material secondary to repeated punctures and stenosis-occlusive lesions in drainage veins represents one of the most common causes of pseudoaneurysms.<span class="elsevierStyleSup">1</span> In our case, the prosthetic material was worn down, in addition to a stenosis/occlusive lesion of the venous drainage and bleeding of one of the pseudoaneurysms, with oedema in the leg.</p><p class="elsevierStylePara">Traditionally, pseudoaneurysms were treated with open surgery; this procedure consisted of replacing the damaged segment of the graft, and if this were impossible, the vascular access was abandoned and another was created. Our patient had exhausted all options of vascular access, for which we decided to preserve the existing one.</p><p class="elsevierStylePara">Since the first publication by Sapoval in 1996, several cases have been reported in which aneurysms and pseudoaneurysms of vascular accesses were treated using an endovascular approach by placing a stent graft, with a success rate of as high as 100% according to some studies.<span class="elsevierStyleSup">2,3</span></p><p class="elsevierStylePara">The use of thrombin as an embolising agent has been widely studied in the treatment of femoral pseudoaneurysms, and this technique currently constitutes the standard practice for treating uncomplicated pseudoaneurysms. In the treatment of pseudoaneurysmal lesions of vascular accesses, we only have case reports of its isolated use<span class="elsevierStyleSup">4</span> or in association with a stent graft.<span class="elsevierStyleSup">5</span> Even so, we have not found any reference in the medical literature to the treatment of 3 pseudoaneurysms in the same patient using different techniques, in addition to revascularisation of the venous drainage system of a femoral loop.</p><p class="elsevierStylePara">Although the treatment of a vascular access with these characteristics may be the subject of debate, we believe that this was the best option in our case, since this was a patient with no other options for a vascular access.</p><p class="elsevierStylePara">Currently, endovascular treatment offers various alternatives for the treatment of this type of lesion, and so must be considered prior to programming surgery or abandoning the vascular access.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors have no conflicts of interest to declare</p><p class="elsevierStylePara"><a href="grande/11624_16025_35729_en_f111624.jpg" class="elsevierStyleCrossRefs"><img src="11624_16025_35729_en_f111624.jpg" alt="Fistulographies"></img></a></p><p class="elsevierStylePara">Figure 1. Fistulographies</p><p class="elsevierStylePara"><a href="grande/11624_16025_35730_en_f2116242.jpg" class="elsevierStyleCrossRefs"><img src="11624_16025_35730_en_f2116242.jpg" alt="Stent, fluoroscopic images, and fistulography"></img></a></p><p class="elsevierStylePara">Figure 2. Stent, fluoroscopic images, and fistulography</p>" "pdfFichero" => "P1-E543-S3700-A11624-EN.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11624_16025_35729_en_f111624.jpg" "Alto" => 789 "Ancho" => 1388 "Tamanyo" => 436934 ] ] "descripcion" => array:1 [ "en" => "Fistulographies" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11624_16025_35730_en_f2116242.jpg" "Alto" => 568 "Ancho" => 1388 "Tamanyo" => 355122 ] ] "descripcion" => array:1 [ "en" => "Stent, fluoroscopic images, and fistulography" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48 Suppl 1:S176-247. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16813989" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Vesely TM. Use of stent grafts to repair hemodialysis graft-related pseudoaneurismas. J Vasc Interv Radiol 2005;16(10):1301-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16221899" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Barshes NR, Annambhotla S, Bechara C, Kougias P, Huynh TT, Dardik A, et al. Endovascular repair of hemodialysis graft-related pseudoaneurysm: an alternative treatment strategy in salvaging failing dialysis access. Vasc Endovascular Surg 2008;42:228-34. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18375603" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ananthakrishanan G, Bhat R, Severn A, Chakraverty S. Stent graft exclusion of pseudo-aneurysm arising from PTFE hemodialysis graft after recurrence following ultrasound guided thrombin injection. 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Semin Dial 2008;21(6):553-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18764789" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003200000005/v0_201502091606/X2013251412001775/v0_201502091607/en/main.assets" "Apartado" => array:4 [ "identificador" => "35437" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor - Brief Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003200000005/v0_201502091606/X2013251412001775/v0_201502091607/en/P1-E543-S3700-A11624-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251412001775?idApp=UINPBA000064" ]
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| 2024 August | 61 | 51 | 112 |
| 2024 July | 41 | 29 | 70 |
| 2024 June | 88 | 30 | 118 |
| 2024 May | 78 | 28 | 106 |
| 2024 April | 53 | 26 | 79 |
| 2024 March | 48 | 23 | 71 |
| 2024 February | 40 | 29 | 69 |
| 2024 January | 41 | 28 | 69 |
| 2023 December | 42 | 19 | 61 |
| 2023 November | 52 | 25 | 77 |
| 2023 October | 42 | 31 | 73 |
| 2023 September | 27 | 32 | 59 |
| 2023 August | 43 | 22 | 65 |
| 2023 July | 54 | 23 | 77 |
| 2023 June | 53 | 25 | 78 |
| 2023 May | 68 | 38 | 106 |
| 2023 April | 45 | 19 | 64 |
| 2023 March | 56 | 19 | 75 |
| 2023 February | 46 | 27 | 73 |
| 2023 January | 42 | 22 | 64 |
| 2022 December | 42 | 24 | 66 |
| 2022 November | 69 | 29 | 98 |
| 2022 October | 43 | 40 | 83 |
| 2022 September | 48 | 23 | 71 |
| 2022 August | 54 | 36 | 90 |
| 2022 July | 36 | 43 | 79 |
| 2022 June | 65 | 39 | 104 |
| 2022 May | 35 | 32 | 67 |
| 2022 April | 31 | 39 | 70 |
| 2022 March | 27 | 39 | 66 |
| 2022 February | 41 | 37 | 78 |
| 2022 January | 39 | 41 | 80 |
| 2021 December | 41 | 46 | 87 |
| 2021 November | 25 | 34 | 59 |
| 2021 October | 48 | 40 | 88 |
| 2021 September | 43 | 38 | 81 |
| 2021 August | 41 | 33 | 74 |
| 2021 July | 50 | 30 | 80 |
| 2021 June | 64 | 21 | 85 |
| 2021 May | 36 | 36 | 72 |
| 2021 April | 122 | 53 | 175 |
| 2021 March | 60 | 30 | 90 |
| 2021 February | 23 | 6 | 29 |
| 2021 January | 20 | 11 | 31 |
| 2020 December | 26 | 11 | 37 |
| 2020 November | 28 | 12 | 40 |
| 2020 October | 24 | 15 | 39 |
| 2020 September | 30 | 16 | 46 |
| 2020 August | 46 | 9 | 55 |
| 2020 July | 25 | 9 | 34 |
| 2020 June | 28 | 6 | 34 |
| 2020 May | 37 | 10 | 47 |
| 2020 April | 31 | 18 | 49 |
| 2020 March | 35 | 6 | 41 |
| 2020 February | 41 | 20 | 61 |
| 2020 January | 49 | 22 | 71 |
| 2019 December | 51 | 24 | 75 |
| 2019 November | 36 | 20 | 56 |
| 2019 October | 19 | 6 | 25 |
| 2019 September | 28 | 12 | 40 |
| 2019 August | 24 | 7 | 31 |
| 2019 July | 29 | 20 | 49 |
| 2019 June | 30 | 10 | 40 |
| 2019 May | 24 | 20 | 44 |
| 2019 April | 69 | 52 | 121 |
| 2019 March | 32 | 22 | 54 |
| 2019 February | 25 | 19 | 44 |
| 2019 January | 35 | 22 | 57 |
| 2018 December | 88 | 29 | 117 |
| 2018 November | 92 | 15 | 107 |
| 2018 October | 110 | 11 | 121 |
| 2018 September | 96 | 8 | 104 |
| 2018 August | 42 | 13 | 55 |
| 2018 July | 50 | 13 | 63 |
| 2018 June | 53 | 10 | 63 |
| 2018 May | 70 | 10 | 80 |
| 2018 April | 63 | 11 | 74 |
| 2018 March | 59 | 11 | 70 |
| 2018 February | 81 | 8 | 89 |
| 2018 January | 79 | 8 | 87 |
| 2017 December | 79 | 8 | 87 |
| 2017 November | 53 | 7 | 60 |
| 2017 October | 39 | 6 | 45 |
| 2017 September | 36 | 8 | 44 |
| 2017 August | 31 | 2 | 33 |
| 2017 July | 51 | 12 | 63 |
| 2017 June | 37 | 7 | 44 |
| 2017 May | 38 | 8 | 46 |
| 2017 April | 49 | 8 | 57 |
| 2017 March | 29 | 2 | 31 |
| 2017 February | 41 | 4 | 45 |
| 2017 January | 25 | 1 | 26 |
| 2016 December | 41 | 3 | 44 |
| 2016 November | 52 | 4 | 56 |
| 2016 October | 119 | 5 | 124 |
| 2016 September | 148 | 3 | 151 |
| 2016 August | 123 | 1 | 124 |
| 2016 July | 119 | 5 | 124 |
| 2016 June | 110 | 0 | 110 |
| 2016 May | 122 | 0 | 122 |
| 2016 April | 92 | 0 | 92 |
| 2016 March | 101 | 0 | 101 |
| 2016 February | 124 | 0 | 124 |
| 2016 January | 92 | 0 | 92 |
| 2015 December | 133 | 0 | 133 |
| 2015 November | 107 | 0 | 107 |
| 2015 October | 90 | 0 | 90 |
| 2015 September | 59 | 0 | 59 |
| 2015 August | 86 | 0 | 86 |
| 2015 July | 52 | 0 | 52 |
| 2015 June | 35 | 0 | 35 |
| 2015 May | 37 | 0 | 37 |
| 2015 April | 6 | 0 | 6 |
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