Outcomes of a Multimodality Program for Pseudoaneurysms in Dialysis Access

Abstract

Maintenance of long-term arteriovenous access is an important component in the long-term care of the patient with end-stage renal disease. Arteriovenous access is associated in the longer term with development of pseudoaneurysms (PA). The aim of this study is to evaluate the outcomes of staged PA treatment in dialysis access arteriovenous fistulas (AVF). A retrospective review of all patients over a 10-year period with primary autogenous AVF (radiocephalic, brachiocephalic, and brachiobascilic) was undertaken at a single center. Patients undergoing elective PA repair were identified and were categorized having one or two PA and undergoing single or two stage interventions resulting on the following groupings: open single PA, endovascular single PA, open one stage and two stage two PA, and endovascular two PA repair PA modalities. The 30-day outcomes, cannulation failure, line placement reintervention, and functional dialysis (continuous hemodialysis for 3 consecutive months) were examined. From January 1999 to December 2019, 2291 patients, (67% female; mean age of 61 ± 15 years) underwent primary AVF placement (22% radiocephalic, 53% brachiocephalic, and 45% brachiobascilic). The majority of patients were diabetic and Hispanic. Of these patients, 23% presented with PA that met requirements for intervention; of these 527 patients, 22% underwent endovascular repair, 44% had a single PA and remainder (56%), had two PA repairs (Table). The 30-day major adverse cardiovascular event and 30-day morbidity rates were equivalent across all modalities (Table). Early thrombosis was significantly different across intervention groups, which led to increase need for a tunneled catheter. Simultaneous treatment of two PA by either open or endovascular modalities resulted in an increased incidence of line placement and secondary procedures (Table). Functional dialysis at 5 years was equivalent across the modalities. Open and endovascular interventions are successful therapeutic modalities for PA but staged rather than simultaneous repair results in a lower reintervention rate and a need for interim tunneled central line. TableOpen single PA repairEndo single PA repairOpen one stage 2 PA repairOpen two staged 2 PA repairEndovascular one stage 2 PA repairP valuePatients, No.153791161423730-day major adverse coronary events0.7%1.3%1.7%0.7%2.7%.7830-Day morbidity1.3%1.3%1.7%1.4%2.7%.98Need for a tunneled line2%4%6%3%16%.00230-Day thrombosis1.3%2.5%4.3%2.1%10.8%.0430-Day cannulation failure1.3%2.5%4.3%2.1%5.4%.21No. of secondary interventions per year2.12.33.12.73.4.04Functional dialysis at 5 years82%79%75%79%69%.42PA, Pseudoaneurysm. Open table in a new tab