Hybrid Management of a False Aneurysm Complicating an Arteriovenous Graft in a Patient with Critical Limb Ischemia

Abstract

End-stage renal diabetic patients undergoing dialysis through an arteriovenous graft (AVG) often present with multiple graft complications which demand a combined therapeutic approach. We report a case of a male suffering from a pseudoaneurysm and venous outflow stenosis of his thigh AVG, as well as from critical limb ischemia caused by multiple significant stenoses of the femoropopliteal arterial segment. The patient was managed in a single session with a combination of classic open surgical and endovascular techniques in order to treat his aneurysm, salvage the AVG and to revascularize his leg. This case illustrates the prospect of combining classic open surgical and endovascular techniques for the optimal management of complicated AVGs. Using the hybrid approach in these cases one can succeed in optimizing the result, while simultaneously minimizing the overall risk for the patient.

Three-Year Delayed Presentation of Femoral Pseudoaneurysm after Penetrating Limb Trauma

“…Hybrid open and endovascular approaches are useful for complex cases such as the previously described successfully managed pseudoaneurysm with venous outflow stenosis of a thigh AVG. 22 Delay in diagnosis and definitive surgical management can result in disastrous sequelae of complications as demonstrated by 1 case series of 6 children with lower limb vascular injuries in which diagnostic delay resulted in 2 major amputations and 1 insensate foot. 20 A report of 3 initially clinically unrecognized lower limb vascular injuries, which were later discovered to be arteriovenous fistulas and false aneurysms, emphasizes the importance of surgeons being aware of subtle clinical signs and arranging early preoperative angiography to ensure prompt diagnosis.…”

“…26 Combined classic open surgical and endovascular techniques were used successfully in a diabetic patient with a pseudoaneurysm and venous outflow stenosis of his thigh arteriovenous graft (AVG), allowing graft salvage and revascularization of this leg. 22 Controversially, 1 old prospective study of 20 arterial injuries, including 1 pseudoaneurysm, managed without surgery suggested nonoperative observation may be a safe and feasible method of managing clinically occult arterial injuries. 27 On review of the literature summarized above, we would recommend an endovascular approach is particularly useful for pseudoaneurysms in difficult access vessels such as the subclavian arteries.…”

Correção cirúrgica de aneurismas saculares de fístula arteriovenosa para hemodiálise utilizando a técnica de aneurismorrafia

“…Procedimentos utilizando técnica endovascular e cirúrgica convencional também podem ser utilizados, conforme exemplo de Kouvelos et al 10 , para o tratamento de FAV com prótese na coxa com aneurisma e estenose associada.…”