Acta chir belg, 2005, 105, 190-193
Brachial Artery Pseudoaneurysm :
a Rare Complication after Haemodialysis Therapy
S. Yildirim*, T. Zafer Nursal*, T. Yildirim**, A. Tarim*, K. Caliskan*
Departments of General Surgery*, Radiology**, Baskent University Adana Teaching and Medical Research Center,
Adana, Turkey.
Key words. Brachial artery ; pseudoaneurysm ; haemodialysis.
Abstract. Haemodialysis patients carry a high risk of pseudoaneurysm due to inadvertent puncture of the brachial artery
during venous cannulation for haemodialysis.
Signs and symptoms are pulsatile mass and a systolic murmur. Complications are rupture, infection, haemorrhage, distal arterial insufficiency, venous thrombosis and neuropathy. Early diagnosis is essential to plan adequate treatment.
Doppler US and angiography usually confirm the lesion accurately. Ultrasound guided compression, percutaneous
injection of thrombin, endovascular covered stent exclusion, aneurysmectomy and surgical repair are different treatment
options.
We report clinical and radiological findings and treatment strategies in four dialysed patients who developed brachial
artery pseudoaneurysms.
Introduction
Case reports
The incidence of iatrogenic arterial lesions has been
increasing due to the increasing use of interventional
radiological procedures such as angioplasty, the
positioning of stents, together with the frequent utilization of diagnostic and therapeutic cardiac catheterization (1).
Vascular access malfunction is the most frequent
cause of hospitalization in long-term haemodialysis
patients (2). Native fistulas are the preferred form of
access in these patients due to their lower complication
rate and better longevity compared with synthetic grafts.
Nonetheless, these fistulas are prone to develop complications, which include venous aneurysms, pseudoaneurysms, venous stenosis, arm oedema, venous hypertension secondary to proximal vein stenosis, bleeding
and thrombosis. With the exception of “steal syndrome”,
arterial complications related to haemodialysis access
are relatively uncommon (3).
Patients undergoing dialysis carry a high risk of arterial complications due to the use of large caliber needles,
systemic heparinization and repeated cannulations of a
surgically created arteriovenous fistula (1). In the period
between 1999 and 2003, we treated four patients with
brachial artery pseudoaneurysms of an arteriovenous fistula (AVF) for haemodialysis.
Case 1
It was a 62-year old male patient with a side-to-side brachiocephalic AVF at the left antecubital region. He was
under haemodialysis for three years ; 3 times a week
during the last 2 years. One day, after haemodialysis, a
pulsatile mass was observed at the left antecubital
region. In the following days, there was progressive
worsening of symptoms, with local erythema and
marked pain at palpation (Fig. 1). A large 10 10 cm
pseudoaneurysm communicating with the distal portion
of the brachial artery was observed by color Doppler
Ultrasonography (DUS) (Fig. 2). Operative findings
revealed an infected pseudoaneurysm surrounded with a
smooth but extremely thin and fragile capsule. After
control of the proximal part of the brachial artery, the
pseudoaneurysm was evacuated and the observed 2 mm
defect in the arterial wall was primarily closed.
Satisfactory patency of the brachial artery was confirmed at postoperative control DUS.
Case 2
A 58-year old diabetic, hypertensive patient with a sideto-side brachiocephalic AVF at the left antecubital
region had been under haemodialysis for 2 years. Three
Brachial Artery Pseudoaneurysm
Fig. 1
Photography of the infected pseudoaneurysm
191
Fig. 3
Power Doppler sonogram reveals patent pseudoaneurysm originating from brachial artery.
Case 3
Fig. 2
Color Doppler sonogram shows partially thrombosed large
pseudoaneurysm.
days after the haemodialysis, a mass in the left antecubital fossa appeared. The color and power DUS documented an 80 63 mm pulsating haematoma, originating from the anterior wall of the brachial artery
(Fig. 3). Ultrasound-guided compression repair (UGCR)
was attempted but was unsuccessful. During surgery,
brachial artery pseudoaneurysm and a 1 cm defect on
the arterial wall were confirmed. Furthermore, a partial
thrombus in the brachial artery and a complete obstructing thrombus in the radial artery were present.
Thrombectomy was performed with a 4F Fogarty
catheter and the arterial wall defect was repaired with an
autologous vein graft. Systemic anticoagulation with
heparin was started postoperatively. One day after the
operation, ischaemic changes were observed at the 4th
and 5th digits, which were amputated 1 week after the
operation. Three months after the operation there were
no additional problems and satisfactory outcome of the
surgery was confirmed by color DUS.
It was a 38-year old hypertensive patient with an AVF at
the right snuff-box region. He was receiving haemodialysis treatment three times a week for about 3 years. One
day after a regular haemodialysis session, we found that
a subcutaneous mass had developed at the blood access
puncture point, above the brachial artery at the antecubital region. Color DUS was performed and a 4 4 cm pulsating haematoma originating from the brachial
artery was observed. Brachial artery laceration was confirmed at surgery and a 2 mm defect on the arterial wall
was primarily sutured. The postoperative control DUS
showed satisfactory patency of the brachial artery.
Case 4
It was a 35-year old male patient who has been undergoing haemodialysis for 3 years ; three times a week
through a Brescio-Cimino AVF. Seven days after a
haemodialysis session, a mass in the left antecubital
fossa was observed. Color DUS and brachial artery
angiography were performed and showed a 6 3.5 cm
pseudoaneurysm originating from the brachial artery
(Fig. 4). The patient underwent surgical repair and the
pseudoaneurysm was evacuated. The 2 mm defect on the
arterial wall was primarily repaired. There were no additional circulatory problems after the operation.
Discussion
The most frequent iatrogenic complication after diagnostic, therapeutic, or accidental punctures of the vascular system are pseudoaneurysms and AVF (1). Pseudoaneurysm is an infrequent, but well-documented
complication of the femoral and brachial artery
catheterization used in complex percutaneous vascular
192
Fig. 4
Brachial angiography show 6 3.5 cm partially thrombosed
pseudoaneurysm of the brachial artery. Origin of the radial
artery is high.
procedures (1-2, 4). They usually occur at the puncture
site. Various reports exist on this topic focus on the
femoral artery because of its use in many diagnostic procedures. The vascular injury rate associated with these
procedures has significantly declined, from more than
20% in the 1970’s to less than 1% today (4-6).
Brachial artery pseudoaneurysms are mainly caused
by trauma, cannulation or arterial blood gas sampling (1-2, 7-10).
The patients undergoing haemodialysis are at high
risk of developing iatrogenic pseudoaneurysms because
of repeated cannulation of their surgically created AVF
and concomitant heparinization. Although these patients
seem to be under an increased risk of pseudoaneurysms,
a review of the literature revealed very few cases of false
aneurysms of the radial or brachial artery in haemodialysis patients (1-2, 11-14). The main cause of the
arterial pseudoaneurysm in our series seems to be the
inadvertent puncture of the brachial artery during
venous cannulation for haemodialysis, as the basilic and
S. Yildirim et al.
cephalic veins are extremely close to the brachial artery.
After penetration of the venipuncture needle, the
brachial artery blood extravasates, leading to characteristic haematoma. In order to decrease inadvertent puncture to the brachial artery ; venous flow should be directed to the cephalic vein, especially at the antecubital fistula. If a brachio-basilic AVF is created, the basilic vein
should be mobilized from its native subfascial bed, to a
subcutaneous tunnel on the anterior surface of the
arm (3).
In our institute, brachial pseudoaneurysm developed
in two patients giving a risk rate of one in 13000 sessions. The other two patients of our series were referred
from other centers.
False aneurysms typically present weeks to months
after blunt or penetrating trauma (1, 7). In our patients,
false aneurysms developed 1-7 days after prolonged
bleeding from the brachial arterial puncture site.
In the presence of a vascular complication, early
diagnosis is essential to plan adequate treatment. The
clinical finding of a pulsatile mass and a systolic bruit in
auscultation usually allows correct diagnosis of the
pseudoaneurysm. The presenting signs and symptoms of
false aneurysms may include neuropathy and venous
thrombosis from pressure on an adjacent nerve and
veins. Rupture of the false aneurysm, infection, haemorrhage and distal vascular insufficiency are other possible
consequences (1-2, 7-8). We have observed arterial
insufficiency in one of our patients (case 2). In spite of
the successful removal of aneurysm and satisfactory
thrombectomy, the 4th and 5th digits of the left hand were
amputated because of this arterial insufficiency. In case
1 infection was apparent, surrounding the aneurysm.
Preoperative arteriography or ultrasonography usually confirm the nature and localization of the lesion accurately.
Different treatment options for pseudoaneurysm are
currently available. In the past, standard mode of treatment for these aneurysms was immediate surgical repair
to avoid the risk of rupture. However, since FELLMETH’s
description in 1991, UGCR has become the first line
therapy for nonoperative treatment of the arterial
pseudoaneurysms (15). In this procedure, pressure is
applied with the ultrasound transducer over the center of
the neck of the pseudoaneurysm until the flow through
the neck is stopped. Pressure is maintained for 10 to
20 minutes and then slowly released. If flow is still
present, compression is immediately resumed. This
cycle is repeated until the flow in the pseudoaneurysm is
eliminated. The typical success rate is between 60% and
90% (15-16). UGCR is a good alternative to surgical
repair and has become the primary method of treatment
in many institutions. However, it also presents a number
of disadvantages, including high failure and recurrence
rates in patients under anticoagulation. In addition, the
Brachial Artery Pseudoaneurysm
procedure requires long compression times. Furthermore, compression is painful for the patient and usually
requires intravenous sedation (16-17). More recently
and newly developed, less invasive treatments like the
percutaneous injection of thrombin, endovascular
covered stent exclusion, have been advocated as an alternative to UGCR in the treatment of arterial pseudoaneurysm (13, 16-19). In most studies thrombin injection is found to be a superior technique to compression
and up to 90% success rates were reported (16-17).
Because of the risk of pressure to adjacent structures,
inflammation, and distal arterial insufficiency, rupture
necessitates an urgent surgical approach. Following
proximal and distal vascular control, the false aneurysm
sac is evacuated and arterial wall repair is performed by
primary sutures. End-to-end anastomosis or insertion of
a patch or autologous tubular vein graft are also acceptable depending on the size of the defect. We performed
primary closure in three patients. In the remaining
patient, repair was done by insertion of an autologous
vein graft.
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S. Yildirim
Baskent University Adana Hospital
Dadaloglu Mah. 39. sok
TUR-Yüregir 01250, Adana, Turkey
Tel.
: + 90 322 3272727 int.1134
Fax
: + 90 322 32271273
E-mail : ysedat@hotmail.com