Mestres Gaspar, Barahona Fabricio, Yugueros Xavier, Gamé Victoria, Gil-Sala Daniel, Blanco Carla, Fontseré Nestor, Riambau Vincent
Vascular Surgery Department, Vascular Access Unit, Hospital Clinic, University of Barcelona, Spain.
Vascular Surgery Department, Vascular Access Unit, Hospital Clinic, University of Barcelona, Spain.
Eur J Vasc Endovasc Surg. 2023 Dec;66(6):849-854. doi: 10.1016/j.ejvs.2023.08.063. Epub 2023 Sep 1.
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 transplantation with immunosuppressive therapy. This study aimed to describe the outcomes of surgical treatment and long term follow up in a large cohort.
This prospective cohort study collected data from patients with a true inflow artery aneurysm after AVF creation that was surgically repaired between 2010 and 2022. Anastomotic and 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.
During the study period, 28 patients (64% men, mean age 60.1 years) were treated surgically for aneurysmal degeneration of the axillary or brachial (n = 23) or radial (n = 5) artery after an AVF (10 distal, 18 proximal) performed a mean of 18.3 ± SD 7.9 years previously. 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 or 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 vein, 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 hospital stay 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 interposition graft (one with further late infected pseudoaneurysm) and an asymptomatic post-traumatic graft thrombosis. Five year primary and secondary patency was 84% and 96%, respectively.
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.
流入动脉动脉瘤是长期动静脉内瘘（AVF）后罕见但严重的并发症，可能是由于血流量和剪切应力增加后动脉壁重塑以及肾移植和免疫抑制治疗所致。本研究旨在描述一大群患者手术治疗的结果及长期随访情况。
这项前瞻性队列研究收集了2010年至2022年间接受手术修复的AVF术后真性流入动脉动脉瘤患者的数据。排除吻合口动脉瘤、感染性动脉瘤或穿刺后假性动脉瘤。记录人口统计学数据、血管通路特征、症状、治疗策略及长期随访情况；使用Kaplan-Meier生存分析评估通畅率。
在研究期间，28例患者（64%为男性，平均年龄60.1岁）因AVF（10例为远端，18例为近端）术后腋动脉或肱动脉（n = 23）或桡动脉（n = 5）的动脉瘤样变性接受手术治疗，AVF平均于18.3±标准差7.9年前进行。大多数AVF被结扎或血栓形成，除1例患者外，所有患者此前均接受过肾移植。大多数病例（n = 18）有症状：13例有疼痛或肿胀，4例有远端栓塞，1例破裂。通过动脉瘤部分切除并植入移植物（11例使用大隐静脉，6例使用同侧贵要静脉，3例使用头静脉，2例使用聚四氟乙烯移植物）、结扎（n = 3）或直接端端吻合（n = 3）进行修复。平均住院2.4天后，出院前未发生重大并发症。平均随访4.8±3.3年后，3例出现并发症：2例复发性近端肱动脉瘤通过额外植入近端移植物修复（1例后期出现感染性假性动脉瘤），1例出现无症状创伤后移植物血栓形成。5年的一期和二期通畅率分别为84%和96%。
流入动脉的动脉瘤样变性是AVF长期随访中不常见的并发症。动脉瘤切除，一般采用大隐静脉或同侧手臂静脉自体移植物植入，是一种安全有效的策略。
