What is the recommended treatment for a pseudoaneurysm (false aneurysm) following hemodialysis fistula creation?

Management of Pseudoaneurysm Following Hemodialysis Fistula Creation

Vascular surgical consultation is the primary recommendation for pseudoaneurysm following hemodialysis fistula creation, with surgical resection and interposition graft placement as the definitive treatment, particularly when the pseudoaneurysm exceeds twice the graft diameter, shows rapid expansion, threatens skin viability, or is infected. 1

Risk Stratification and Urgent Indications

Immediate surgical intervention is mandatory when any of the following are present 1:

• Skin erosion or active hemorrhage (surgical emergency)
• Marked skin thinning, ulceration, or eschar formation
• Suspected infection (superficial or deep)
• Spontaneous bleeding from the access site

Treatment Algorithm Based on Clinical Presentation

For Infected or High-Risk Pseudoaneurysms

• Avoid endovascular intervention entirely if infection is suspected or confirmed 1
• Proceed directly to vascular surgical consultation for resection and interposition graft placement 1
• The graft is tunneled in situ or extra-anatomically depending on infection presence 1
• Never cannulate the pseudoaneurysm as needle insertion risks hemorrhage 1

For Non-Infected Pseudoaneurysms

Surgical resection with interposition graft remains indicated when 1:

• Pseudoaneurysm exceeds twice the diameter of the graft
• Rapid expansion in size is documented
• Overlying skin viability is threatened
• Size continues to increase despite observation

Limited Role for Endovascular Approaches

Fluoroscopic fistulography with endovascular stent graft placement may be considered only in highly select cases without infection 1:

• Patency rates of 81.5% at mean 268.9 days follow-up have been reported 1
• However, complication rates are substantial at 28.9% 1
• Relative risk ratio of 5 for stent graft complications compared to stenosis treatment alone 1
• Treatment failure rate of 18.5%, with most failures requiring surgical repair due to infection 1

Fistulography prior to surgery can identify and treat underlying venous outflow stenosis that may have precipitated the pseudoaneurysm formation 1

For Poor Surgical Candidates

Endovascular occlusion with vascular plugs may be considered for patients at high rupture risk who cannot tolerate surgery 1

Bridging Dialysis Access

When surgical intervention is planned 1:

• Place a tunneled dialysis catheter as temporary bridging therapy
• If systemic infection or bacteremia is suspected, treat infection first before tunneled catheter placement
• Temporary non-tunneled catheter can provide immediate access during infection treatment
• Tunneled catheters carry higher mortality and infection risk compared to AVF/AVG, so use only as temporizing measure 1

Critical Distinctions: Pseudoaneurysm vs True Aneurysm

True aneurysms of native AV fistulae have a benign natural history and require intervention only when involving the arterial anastomosis 1. This contrasts sharply with pseudoaneurysms, which carry significant rupture risk and require more aggressive management.

Common Pitfalls to Avoid

• Do not attempt cannulation of the pseudoaneurysm or surrounding area 1
• Do not pursue endovascular treatment if any signs of infection exist 1
• Do not delay surgical consultation when high-risk features are present, as rupture can result in life-threatening hemorrhage 1
• Recognize that endovascular approaches have substantially higher complication rates for pseudoaneurysms compared to other access complications 1