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Case Report

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JKDA 2023; 6(2): 66-69

Published online November 25, 2023

https://doi.org/10.56774/jkda23010

© Korean Society of Dialysis Access

Balloon-assisted Percutaneous Thrombin Injection for Brachial Artery Pseudoaneurysm after AV Fistula Cannulation

Doo Ri Kim, In Chul Nam, Jeong Jae Kim

Department of Radiology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea

Correspondence to : In Chul Nam
Department of Radiology, Jeju National University Hospital, Jeju National University School of Medicine, 15, Aran 13-gil, Jeju 63241, Korea
Tel: 82-64-717-1382, Fax: 82-64-717-1377, E-mail: sky_hall@naver.com

Received: September 6, 2023; Revised: October 16, 2023; Accepted: October 18, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Pseudoaneurysms of arteriovenous fistulas (AVF) are often requiring surgical intervention. Herein, a male patient undergoing hemodialysis developed a brachial artery pseudoaneurysm of a radiocephalic AVF and presented with edema and pain in the right arm. Fistulography and ultrasonography revealed a brachial artery pseudoaneurysm. To prevent the potential migration of the thrombus to the brachial artery, we administered an ultrasound-guided percutaneous thrombin injection (UGTI), assisted by a balloon inflation in the brachial artery lumen. At 1-year follow-up, the AVF access remained functional. The balloon-assisted percutaneous UGTI could be an effective nonsurgical treatment for AVF pseudoaneurysms and vascular access maintenance.

Keywords Arteriovenous fistula, Pseudoaneurysm, Thrombin

Pseudoaneurysms in arteriovenous fistula (AVF) access sites are relatively common and well-recognized complications involving the draining vein, prosthesis, and rarely the artery [1]. A pseudoaneurysm or hematoma can occur in an AVF after vessel injury due to repeated cannulation, failed cannulation, or hemodialysis (HD) needle removal [2]. Unlike true aneurysms, pseudoaneurysms do not have walls. Instead, they maintain a connection with the main vessel through a defect or neck and are confined by the surrounding layer of reactive fibrous tissue lined by the endothelium [3]. A small pseudoaneurysm occurring in the draining vein may not be treated but may undergo clinical surveillance if it has stable dimensions. However, arterial pseudoaneurysms tend to increase regardless of the dimension due to the high pressure of the artery and should always be treated, usually by open surgery [3,4].

We report the successful treatment of a brachial artery pseudoaneurysm in a radiocephalic AVF using balloon-assisted ultrasound-guided percutaneous thrombin injection (UGTI).

A 76-year-old male with chronic glomerulonephritis and long-standing hypertension visited our hospital and was referred to our department for an acute onset of right arm swelling and pain after failed cannulation of radiocephalic AVF. He had undergone AVF creation surgery 4 months ago. We had performed salvation AVF percutaneous transluminal angioplasty and coil embolization for a prominent collateral vein a month ago due to maturation failure. AVF access was unused, and the patient had a history of cerebrovascular disease, right nephrectomy for chronic glomerulonephritis, and implantation of a single-chamber internal pulse generator for arrhythmia. The patient was administered anticoagulants.

He presented with bruising, swelling, and pain in the right arm. All symptoms and signs developed following a failed attempt at AVF cannulation in a dialysis room. Thrill in the arm along the fistula tract was weak on physical examination; however, a pulsatile lesion was also felt near the elbow. The pain was controlled by the administration of analgesics. Fistulography performed via retrograde access to the draining vein revealed an immature AVF with no significant stenosis or occlusion. Arteriography, which was conducted by advancing a guiding catheter to the upper brachial artery, confirmed the presence of a pseudoaneurysm in the lower brachial artery (Fig. 1). First, we attempted coil embolization of the pseudoaneurysm by selecting it directly using a microcatheter and microwire. However, this method failed because the neck of the AVF was very short, and the orifice was small, only allowing the microwire to pass through and not the microcatheter. Thus, we chose to treat the pseudoaneurysm with UGTI assisted by balloon inflation to ensure complete thrombosis of the pseudoaneurysm and avoid thrombus migration into the arterial circulation. The procedure was performed under local anesthesia with 7×40 mm balloon inflation in the brachial artery, enough to cover the orifice of the pseudoaneurysm (Fig. 2A). After inflating the balloon catheter, we carefully injected thrombin (400 IU/0.8 cc) under ultrasound guidance and waited for 2 min with the inflated balloon until complete thrombosis of the pseudoaneurysm was achieved (Fig. 2B). Final ultrasonography (Fig. 2C) and arteriography (Fig. 3) revealed complete embolization of the pseudoaneurysm. Because the patient’s AVF had not yet matured, we determined that the AVF could not be used for the time being and performed tunneled catheter insertion. The patient underwent HD through a tunneled catheter over the following 3 months. Three months after the procedure, the AVF matured enough to initiate HD, and the patient maintained functional AVF access with no intercurrences.

Fig. 1.Brachial arteriography revealed a small pseudoaneurysm in lower brachial artery.

Fig. 2.(A) After completely occluding the lumen of the brachial artery with a 7×40 mm balloon catheter (asterisk), a direct puncture of the pseudoaneurysm was performed using a needle under ultrasound guidance (white arrow). (B) Thrombin (400 IU/0.8 cc) was injected carefully under ultrasound guidance. (C) Final ultrasonography shows complete embolization of pseudoaneurysm.

Fig. 3.Final brachial arteriography reveals successful exclusion of pseudoaneurysm.

Diagnosis of end-stage renal disease cases is becoming increasingly common; consequently, the demand for HD is increasing. AVFs continue to be the preferred method for effective HD, as they are associated with fewer long-term complications than alternatives, such as bypass grafts and central venous catheters [5]. Arteriovenous vascular accesses used for HD do not last forever, and their natural life course involves multiple revision procedures to save and maintain access. Protecting access routes for dialysis is a priority. Regular vascular access evaluation through hands-on examinations in the dialysis unit plays a critical role in identifying complications.

The incidence of pseudoaneurysms in AVF access is a relatively common and well-recognized complication that has been reported to be between 2% and 10% in grafts [6], whereas it is rare in AVF [6,7]. A pseudoaneurysm or hematoma can occur in an AVF after a traumatic injury to the vessel due to repeated cannulation, failed cannulation, or HD needle removal [2]. Traditionally, conventional surgery has been the gold standard treatment for arterial pseudoaneurysm. However, several recent reports have revealed that interventional treatments can preserve AVF vascular access and treat pseudoaneurysms without major complications.

In our case, we initially planned direct coil embolization; however, this method failed because the microcatheter could not pass through. Additionally, coil embolization for pseudoaneurysms is known to have a higher risk of rebleeding and rupture, which is not favorable in the long-term perspective [8]. Another method to exclude arterial pseudoaneurysms is covered stent insertion [6], but this was not easy because the pseudoaneurysm location at the elbow overlapped with the joint's range of motion. Fortunately, direct thrombin injection is possible because the pseudoaneurysm is located superficially. Although rare, complications, including thrombus migration, infection, and allergic reactions to bovine thrombin, can occur [9]. Therefore, we considered percutaneous UGTI assisted by balloon inflation, which allowed occlusion of the arterial lumen to achieve complete thrombosis and avoid thromboembolism. In a recent prospective study involving 53 patients with active bleeding, only those with noncompressible bleeding or who failed manual compression (after at least 30 minutes of compression) were treated with balloon-assisted thrombin injection. The overall success rate was 94%, the recurrence rate was 12%, and the complication rate was 4%. This method appears to be feasible and safe when performed by experienced operators [10]. The patient showed no recurrence during the 13-month follow-up period.

In conclusion, percutaneous thrombin injection supported by a balloon inflated in the artery could effectively treat arterial pseudoaneurysms after failed HD cannulation in the AVF tract. This endovascular technique could be an alternative for patients in whom surgery is challenging or where preserving the AVF vascular access is desired.

There were no presentations in academic contests.

This study received no external funding.

  1. Beigh A, Mazumder MA. Successful treatment of a brachial artery pseudoaneurysm in a brachiobasilic arteriovenous fistula using ultradsound-guided manual compression. J Ultrasound 2023; 26(4): 955-7.
    Pubmed CrossRef
  2. Loureiro L, Mendes D, Sousa CN, Almeida P, Matos AN, Teles P, Rego D, Teixeira G, Teixeira S, Antunes I, Costa LL. Ruptured arteriovenous fistula pseudoaneurysm treatment by balloon-assisted direct percutaneous thrombin injection. Semin Dial 2022; 35(2): 194-7.
    Pubmed CrossRef
  3. Meola M, Marciello A, Salle GD, Petrucci I. Ultrasound evaluation of access complications: Thrombosis, aneurysms, pseudoaneurysms and infections. J Vasc Access 2021; 22(1 suppl): 71-83.
    Pubmed KoreaMed CrossRef
  4. Mudoni A, Cornacchiari M, Gallieni M, Guastoni C, McGrogan D, Logias F, Ferramosca E, Mereghetti M, Inston N. Aneurysms and pseudoaneurysms in dialysis access. Clin Kidney J 2015; 8(4): 363-7.
    Pubmed KoreaMed CrossRef
  5. Bashar K, Conlon PJ, Kheireslseid EAH, Aherne T, Walsh SR, Leahy A. Arteriovenous fistula in dialysis patients: Factors implicated in early and late AVF maturation failure. Surgeon 2016; 14(5): 294-300.
    Pubmed CrossRef
  6. Najibi S, Bush RL, Terramani TT, Chaikof EL, Gunnoud AB, Lumsden AB, Weiss VJ. Covered stent exclusion of dialysis access pseudoaneurysms. J Surg Res 2002; 106(1): 15-9.
    Pubmed CrossRef
  7. Inston N, Mistry H, Gilbert J, Kingsmore D, Raza Z, Tozzi M, Azizzadeh A, Jones R, Deane C, Wilkins J, Davidson I, Ross J, Gibbs P, Huang D, Valenti D. Aneurysms in vascular access: state of the art and future developments. J Vasc Access 2017; 18(6): 464-72.
    Pubmed CrossRef
  8. Hur S, Yoon CJ, Kang SG, Dixon R, Han HS, Yoon YS, Cho JY. Transcatheter arterial embolization of gastroduodenal artery stump pseudoaneurysms after pancreaticoduodenectomy: safety and efficacy of two embolization techniques. J Vasc Interv Radiol 2011; 22(3): 294-301.
    Pubmed CrossRef
  9. Valesano JC, Schmitz JJ, Kurup AN, Schmit GD, Moynagh MR, Atwell TD, Lewis BD, Lee BA, Callstom MR. Outcomes of ultrasound-guided thrombin injection of nongroin arterial pseudoaneurysms. J Vasc Interv Radiol 2017; 28(8): 1156-60.
    Pubmed CrossRef
  10. Jakob UL, Matthias M, Lukasz S, Alexander J, Mohamed AW, Steffen D, Holger T, Dmitry SS. Balloon-assisted injection of fibrin sealant for the treatment of postintervention access-site bleeding complications. Catheter Cardiovasc Interv 2022; 99(4): 1327-34.
    Pubmed CrossRef

Article

Case Report

JKDA 2023; 6(2): 66-69

Published online November 25, 2023 https://doi.org/10.56774/jkda23010

Copyright © Korean Society of Dialysis Access.

Balloon-assisted Percutaneous Thrombin Injection for Brachial Artery Pseudoaneurysm after AV Fistula Cannulation

Doo Ri Kim, In Chul Nam, Jeong Jae Kim

Department of Radiology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea

Correspondence to:In Chul Nam
Department of Radiology, Jeju National University Hospital, Jeju National University School of Medicine, 15, Aran 13-gil, Jeju 63241, Korea
Tel: 82-64-717-1382, Fax: 82-64-717-1377, E-mail: sky_hall@naver.com

Received: September 6, 2023; Revised: October 16, 2023; Accepted: October 18, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Pseudoaneurysms of arteriovenous fistulas (AVF) are often requiring surgical intervention. Herein, a male patient undergoing hemodialysis developed a brachial artery pseudoaneurysm of a radiocephalic AVF and presented with edema and pain in the right arm. Fistulography and ultrasonography revealed a brachial artery pseudoaneurysm. To prevent the potential migration of the thrombus to the brachial artery, we administered an ultrasound-guided percutaneous thrombin injection (UGTI), assisted by a balloon inflation in the brachial artery lumen. At 1-year follow-up, the AVF access remained functional. The balloon-assisted percutaneous UGTI could be an effective nonsurgical treatment for AVF pseudoaneurysms and vascular access maintenance.

Keywords: Arteriovenous fistula, Pseudoaneurysm, Thrombin

INTRODUCTION

Pseudoaneurysms in arteriovenous fistula (AVF) access sites are relatively common and well-recognized complications involving the draining vein, prosthesis, and rarely the artery [1]. A pseudoaneurysm or hematoma can occur in an AVF after vessel injury due to repeated cannulation, failed cannulation, or hemodialysis (HD) needle removal [2]. Unlike true aneurysms, pseudoaneurysms do not have walls. Instead, they maintain a connection with the main vessel through a defect or neck and are confined by the surrounding layer of reactive fibrous tissue lined by the endothelium [3]. A small pseudoaneurysm occurring in the draining vein may not be treated but may undergo clinical surveillance if it has stable dimensions. However, arterial pseudoaneurysms tend to increase regardless of the dimension due to the high pressure of the artery and should always be treated, usually by open surgery [3,4].

We report the successful treatment of a brachial artery pseudoaneurysm in a radiocephalic AVF using balloon-assisted ultrasound-guided percutaneous thrombin injection (UGTI).

CASE

A 76-year-old male with chronic glomerulonephritis and long-standing hypertension visited our hospital and was referred to our department for an acute onset of right arm swelling and pain after failed cannulation of radiocephalic AVF. He had undergone AVF creation surgery 4 months ago. We had performed salvation AVF percutaneous transluminal angioplasty and coil embolization for a prominent collateral vein a month ago due to maturation failure. AVF access was unused, and the patient had a history of cerebrovascular disease, right nephrectomy for chronic glomerulonephritis, and implantation of a single-chamber internal pulse generator for arrhythmia. The patient was administered anticoagulants.

He presented with bruising, swelling, and pain in the right arm. All symptoms and signs developed following a failed attempt at AVF cannulation in a dialysis room. Thrill in the arm along the fistula tract was weak on physical examination; however, a pulsatile lesion was also felt near the elbow. The pain was controlled by the administration of analgesics. Fistulography performed via retrograde access to the draining vein revealed an immature AVF with no significant stenosis or occlusion. Arteriography, which was conducted by advancing a guiding catheter to the upper brachial artery, confirmed the presence of a pseudoaneurysm in the lower brachial artery (Fig. 1). First, we attempted coil embolization of the pseudoaneurysm by selecting it directly using a microcatheter and microwire. However, this method failed because the neck of the AVF was very short, and the orifice was small, only allowing the microwire to pass through and not the microcatheter. Thus, we chose to treat the pseudoaneurysm with UGTI assisted by balloon inflation to ensure complete thrombosis of the pseudoaneurysm and avoid thrombus migration into the arterial circulation. The procedure was performed under local anesthesia with 7×40 mm balloon inflation in the brachial artery, enough to cover the orifice of the pseudoaneurysm (Fig. 2A). After inflating the balloon catheter, we carefully injected thrombin (400 IU/0.8 cc) under ultrasound guidance and waited for 2 min with the inflated balloon until complete thrombosis of the pseudoaneurysm was achieved (Fig. 2B). Final ultrasonography (Fig. 2C) and arteriography (Fig. 3) revealed complete embolization of the pseudoaneurysm. Because the patient’s AVF had not yet matured, we determined that the AVF could not be used for the time being and performed tunneled catheter insertion. The patient underwent HD through a tunneled catheter over the following 3 months. Three months after the procedure, the AVF matured enough to initiate HD, and the patient maintained functional AVF access with no intercurrences.

Figure 1. Brachial arteriography revealed a small pseudoaneurysm in lower brachial artery.

Figure 2. (A) After completely occluding the lumen of the brachial artery with a 7×40 mm balloon catheter (asterisk), a direct puncture of the pseudoaneurysm was performed using a needle under ultrasound guidance (white arrow). (B) Thrombin (400 IU/0.8 cc) was injected carefully under ultrasound guidance. (C) Final ultrasonography shows complete embolization of pseudoaneurysm.

Figure 3. Final brachial arteriography reveals successful exclusion of pseudoaneurysm.

DISCUSSION

Diagnosis of end-stage renal disease cases is becoming increasingly common; consequently, the demand for HD is increasing. AVFs continue to be the preferred method for effective HD, as they are associated with fewer long-term complications than alternatives, such as bypass grafts and central venous catheters [5]. Arteriovenous vascular accesses used for HD do not last forever, and their natural life course involves multiple revision procedures to save and maintain access. Protecting access routes for dialysis is a priority. Regular vascular access evaluation through hands-on examinations in the dialysis unit plays a critical role in identifying complications.

The incidence of pseudoaneurysms in AVF access is a relatively common and well-recognized complication that has been reported to be between 2% and 10% in grafts [6], whereas it is rare in AVF [6,7]. A pseudoaneurysm or hematoma can occur in an AVF after a traumatic injury to the vessel due to repeated cannulation, failed cannulation, or HD needle removal [2]. Traditionally, conventional surgery has been the gold standard treatment for arterial pseudoaneurysm. However, several recent reports have revealed that interventional treatments can preserve AVF vascular access and treat pseudoaneurysms without major complications.

In our case, we initially planned direct coil embolization; however, this method failed because the microcatheter could not pass through. Additionally, coil embolization for pseudoaneurysms is known to have a higher risk of rebleeding and rupture, which is not favorable in the long-term perspective [8]. Another method to exclude arterial pseudoaneurysms is covered stent insertion [6], but this was not easy because the pseudoaneurysm location at the elbow overlapped with the joint's range of motion. Fortunately, direct thrombin injection is possible because the pseudoaneurysm is located superficially. Although rare, complications, including thrombus migration, infection, and allergic reactions to bovine thrombin, can occur [9]. Therefore, we considered percutaneous UGTI assisted by balloon inflation, which allowed occlusion of the arterial lumen to achieve complete thrombosis and avoid thromboembolism. In a recent prospective study involving 53 patients with active bleeding, only those with noncompressible bleeding or who failed manual compression (after at least 30 minutes of compression) were treated with balloon-assisted thrombin injection. The overall success rate was 94%, the recurrence rate was 12%, and the complication rate was 4%. This method appears to be feasible and safe when performed by experienced operators [10]. The patient showed no recurrence during the 13-month follow-up period.

In conclusion, percutaneous thrombin injection supported by a balloon inflated in the artery could effectively treat arterial pseudoaneurysms after failed HD cannulation in the AVF tract. This endovascular technique could be an alternative for patients in whom surgery is challenging or where preserving the AVF vascular access is desired.

PRESENTATIONS

There were no presentations in academic contests.

FUNDING

This study received no external funding.

Fig 1.

Figure 1.Brachial arteriography revealed a small pseudoaneurysm in lower brachial artery.
Journal of Korean Dialysis Access 2023; 6: 66-69https://doi.org/10.56774/jkda23010

Fig 2.

Figure 2.(A) After completely occluding the lumen of the brachial artery with a 7×40 mm balloon catheter (asterisk), a direct puncture of the pseudoaneurysm was performed using a needle under ultrasound guidance (white arrow). (B) Thrombin (400 IU/0.8 cc) was injected carefully under ultrasound guidance. (C) Final ultrasonography shows complete embolization of pseudoaneurysm.
Journal of Korean Dialysis Access 2023; 6: 66-69https://doi.org/10.56774/jkda23010

Fig 3.

Figure 3.Final brachial arteriography reveals successful exclusion of pseudoaneurysm.
Journal of Korean Dialysis Access 2023; 6: 66-69https://doi.org/10.56774/jkda23010

References

  1. Beigh A, Mazumder MA. Successful treatment of a brachial artery pseudoaneurysm in a brachiobasilic arteriovenous fistula using ultradsound-guided manual compression. J Ultrasound 2023; 26(4): 955-7.
    Pubmed CrossRef
  2. Loureiro L, Mendes D, Sousa CN, Almeida P, Matos AN, Teles P, Rego D, Teixeira G, Teixeira S, Antunes I, Costa LL. Ruptured arteriovenous fistula pseudoaneurysm treatment by balloon-assisted direct percutaneous thrombin injection. Semin Dial 2022; 35(2): 194-7.
    Pubmed CrossRef
  3. Meola M, Marciello A, Salle GD, Petrucci I. Ultrasound evaluation of access complications: Thrombosis, aneurysms, pseudoaneurysms and infections. J Vasc Access 2021; 22(1 suppl): 71-83.
    Pubmed KoreaMed CrossRef
  4. Mudoni A, Cornacchiari M, Gallieni M, Guastoni C, McGrogan D, Logias F, Ferramosca E, Mereghetti M, Inston N. Aneurysms and pseudoaneurysms in dialysis access. Clin Kidney J 2015; 8(4): 363-7.
    Pubmed KoreaMed CrossRef
  5. Bashar K, Conlon PJ, Kheireslseid EAH, Aherne T, Walsh SR, Leahy A. Arteriovenous fistula in dialysis patients: Factors implicated in early and late AVF maturation failure. Surgeon 2016; 14(5): 294-300.
    Pubmed CrossRef
  6. Najibi S, Bush RL, Terramani TT, Chaikof EL, Gunnoud AB, Lumsden AB, Weiss VJ. Covered stent exclusion of dialysis access pseudoaneurysms. J Surg Res 2002; 106(1): 15-9.
    Pubmed CrossRef
  7. Inston N, Mistry H, Gilbert J, Kingsmore D, Raza Z, Tozzi M, Azizzadeh A, Jones R, Deane C, Wilkins J, Davidson I, Ross J, Gibbs P, Huang D, Valenti D. Aneurysms in vascular access: state of the art and future developments. J Vasc Access 2017; 18(6): 464-72.
    Pubmed CrossRef
  8. Hur S, Yoon CJ, Kang SG, Dixon R, Han HS, Yoon YS, Cho JY. Transcatheter arterial embolization of gastroduodenal artery stump pseudoaneurysms after pancreaticoduodenectomy: safety and efficacy of two embolization techniques. J Vasc Interv Radiol 2011; 22(3): 294-301.
    Pubmed CrossRef
  9. Valesano JC, Schmitz JJ, Kurup AN, Schmit GD, Moynagh MR, Atwell TD, Lewis BD, Lee BA, Callstom MR. Outcomes of ultrasound-guided thrombin injection of nongroin arterial pseudoaneurysms. J Vasc Interv Radiol 2017; 28(8): 1156-60.
    Pubmed CrossRef
  10. Jakob UL, Matthias M, Lukasz S, Alexander J, Mohamed AW, Steffen D, Holger T, Dmitry SS. Balloon-assisted injection of fibrin sealant for the treatment of postintervention access-site bleeding complications. Catheter Cardiovasc Interv 2022; 99(4): 1327-34.
    Pubmed CrossRef

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