Incidence of Anastomotic Pseudoaneurysm of Arteriovenous Fistula in Hemodialysis Patients Having Non-Cuffed Catheters as Vascular Access - Association or Causation?

Background: Anastomotic pseudoaneurysm affecting arteriovenous fistula created for hemodialysis is an unusual and catastrophic complication. There is lack of clinical data in literature about its incidence and management. Aims and Objectives: To study the incidence and understand the aetiology of anastomotic pseudoaneurysm of arteriovenous fistula (PA-AVF) occurring in first six months after surgery. Materials and Methods: Cohort study based on retrospective analysis of three-year data of case-series of PA-AVF occurring in first six months after AV fistula creation for hemodialysis. Results: Among the 283 AV fistula surgeries (215 distal forearm radio-cephalic AVF and 68 brachial artery or cubital region AVF), 7 patients (2.4%) developed PA-AVF within 1 to 8 weeks after AV fistula surgery. Over-extended dependence on non-cuffed hemodialysis (HD) catheter was a common factor among patients developing this complication. All the patients had a prolonged stay (34 to 75 days) of non-cuffed HD catheters before development of PA-AVF. Diagnosis of HD catheter-related blood stream infection (HD-CRBSI), which overlapped with development of PA-AVF, was proven in 4 patients, two of which also had surgical site infection. One patient had traumatic PA-AVF and in two patients the cause could not be established although features consistent with CRBSI were present. Excision of pseudoaneurysm and ligation of radial artery was done in all cases. Conclusion: Infection is the most common cause of anastomotic pseudoaneurysm of AV fistula. Our study points towards extended use of non-cuffed hemodialysis catehters as a risk factor for development of PA-AVF. Prevention and early aggressive management of CRBSI and surgical site infections along with a limited use of non-cuffed HD catheters for the minimum required duration is the key to reduce the incidence of this complication