Contemporary management of arteriovenous haemodialysis fistula aneurysms

Abstract

IntroductionAneurysms develop in up to 60% of patients with an arteriovenous fistula. Frequently arteriovenous fistula aneurysms are asymptomatic with the presence of symptoms potentially heralding the development a significant complication. A range of surgical and endovascular techniques are available to manage arteriovenous fistula aneurysms but clinical guidelines regarding the appropriate application of each approach are lacking. This review will examine the presentation, indications for treatment and management options for arteriovenous fistula aneurysms. MethodsA non-systematic review of published literature in the following databases was performed: Medline, ScienceDirect, Scopus and the Cochrane Database of Systematic Reviews. Publications relating to arteriovenous fistula aneurysms and treatment options between January 1973 and June 2016 were considered for inclusion. Articles pertaining to aneurysms and pseudoaneurysms of prosthetic arteriovenous access sites were excluded. The literature search was supplemented by a review of the author's experience. ResultsArteriovenous fistula aneurysms are defined by an expansion of the intimal, medial and adventitial layers of the vessel wall to a diameter of more than 18mm. Treatment of arteriovenous fistula aneurysm is indicated if there is pain, risk of haemorrhage and flow disturbance (either low or high flow). When deciding on whether to actively treat or observe, the diameter of the arteriovenous fistula aneurysm and cosmetic concerns should not be considered in isolation. Commonly applied approaches for treating arteriovenous fistula aneurysm are resection with interposition, remodelling and insertion of an endovascular stent graft. Although various surgical and endovascular options have been reported, there are no prospective studies directly comparing techniques. ConclusionsAsymptomatic aneurysms can be safely observed. Due to a lack of sufficient evidence base, no individual management strategy can currently be recommended for aneuryms requiring treatment. Finally, symptomatic aneurysms, mainly which are in the high risk of bleeding, should be indicated for the treatment as soon as possible.