Inflow Artery Aneurysmal Degeneration After Long Term Native Arteriovenous Fistula for Haemodialysis.

OBJECTIVE: Inflow arterial aneurysms are a rare but serious complication after long term arteriovenous fistulae (AVF), probably due to arterial wall remodelling after an increase in flow and shear stress, and kidney transplant with immunosuppressive therapy. This study aimed to describe the outcomes of surgical treatment and long term follow up in a large cohort.

METHODS: This prospective cohort study collected data from patients with true inflow artery aneurysm after AVF creation that was surgically repaired between 2010 and 2022. Anastomotic/infected aneurysms or post-puncture pseudoaneurysms were excluded. Demographic data, access characteristics, symptoms, treatment strategies, and long term follow up were recorded; patency was estimated using Kaplan-Meier survival analysis.

RESULTS: During the study period, 28 patients (64% men, mean age 60.1 years) were surgically treated for aneurysmal degeneration of the axillary/brachial (n = 23) or radial (n = 5) artery after a previous AVF (10 distal, 18 proximal) performed a mean of 18.3 (SD ± 7.9) years before. Most AVFs were ligated or thrombosed, while all patients except one had previously received kidney transplants. Most of the cases (n = 18) were symptomatic: 13 with pain/swelling, four with distal embolisation, and one rupture. They were repaired by aneurysm partial excision and graft interposition (11 great saphenous vein, six ipsilateral basilic, three cephalic vein, and two PTFE graft), ligation (n = 3), or direct end-to-end anastomosis (n = 3). No major complications occurred before discharge, after a mean hospitalisation of 2.4 days. After a mean follow up of 4.8 (± 3.3) years, three cases presented complications: two recurrent proximal brachial aneurysms were repaired with an additional proximal graft interposition (one with further late infected pseudoaneurysm) and an asymptomatic post-traumatic graft thrombosis. Five year primary and secondary patency was 84% and 96%, respectively.

CONCLUSION: Aneurysmal degeneration of the inflow artery is an unusual complication during long term follow up of AVFs. Aneurysm excision and, in general, autogenous graft interposition using the saphenous or ipsilateral arm vein is a safe and effective strategy.