Novel technique for repair of arteriovenous fistula with aneurysm

Aneurysm of autogenous arteriovenous fistula is a common complication in patients receiving hemodialysis. We present a novel method for repair of a case of aneurysm of arteriovenous fistula resulting from stenosis. A 52-year-old woman presented with aneurysm formation of the left upper arm arteriovenous fistula, with related numbness in the left hand. Clinical examination revealed a tense, pulsatile aneurysm above the brachiocephalic anastomosis. Ultrasound examination revealed an aneurysm (50？mm × 25？mm) with proximal stenosis and an arteriovenous fistula flow rate above 1200 mL/min. An incision was made lateral to the aneurysm from the brachiocephalic anastomosis to the proximal stenosis through the antecubital fossa. After exposure of the entire aneurysmal arteriovenous fistula, the narrowed segment, and the proximal cephalic vein, the aneurysm outflow was ligated and the narrowed segment was removed. A U-shaped incision was made on the aneurysm to create an aneurysmal flap (75？mm × 20？mm). The flap was tubularized after calibration of the lumen with a 14-Fr cannula. End-to-end anastomosis was performed between the distal tubularized flap and the proximal cephalic vein. Intra- and postoperative arteriovenous fistula flow rates were below 900 mL/min. After surgery, the remodeled arteriovenous fistula was immediately usable for hemodialysis with normal arteriovenous fistula flow in the upper arm. The repair technique achieved not only aneurysmorrhaphy but also created an autologous vascular graft as the bypass after removal of the narrowed segment. Moreover, this technique achieved reduced arterial inflow and is suitable for patients with conditions similar to those of this case