Rupture infected pseudoaneurysm on brachiocephalic AV-fistula: emergency and definitive management

ABSTRACT


INTRODUCTION
Vascular access bleeding is a rare event that happens in hemodialysis patients.When it occurs, it can be fatal to the patient. 1 Bleeding can occur to several cause after arteriovenous Fistula construction surgery, such as infection at the surgical site, traumatic event or rupture of a pseudo aneurysm. Bleeding at the vascular access requires surgical emergencies to reduce the risk of ischemic events in the patient's forearm and reduce mortality risk in the patient. 4,5The purpose of this case report is to present a 55-year-old man with bleeding on the AV-fistula surgery site, accompanied with pain and swelling on his forearm that occurred 3 hours before admission to the hospital.

CASE DESCRIPTION
A 55-year-old Man came to our ER because of bleeding on the arteriovenous fistula (AV-fistula) surgery site, accompanied with pain and swelling on his forearm that occurred 3 hours before admission to the hospital.He has been diagnosed with chronic renal failure and underwent hemodialysis for 1 year.The Patient had a history of brachiocephalic AV-fistula surgery 3 weeks earlier.He said that the wound still looked wet and was bleeding at first, on 3 hours earlier, it was bleeding profusely and felt painful.
On physical examination, arterial blood pressure was 150/80 mm Hg; body temperature was 36.5°C;pulse rate 76 beats/min; respiration rate 24 breaths/ min.It was found that the surgical site wound looked wet and swollen, with lots of necrotic tissue and pus and lost stitches.
There was profuse and pulsatile bleeding from the surgical wound.The patient has been diagnosed with a ruptured pseudo aneurysm brachiocephalic anastomotic arteriovenous fistula.
While in the ER, the patient was administered intravenous normal saline fluids, bleeding inhibitors drug and pressure bandages to reduce ongoing bleeding, then the patient had planned for immediate surgery.
The patient then underwent vascular reconstruction surgery under general anesthesia.The first stage of the operation is to clean the operating area of debris and necrotic tissue to free the blood vessels tissue to be reconstructed.
It was found only a few salvageable arterial tissues remained.Then it was decided to do a reconstruction using a side-to-side vein patch plasty technique using a great saphenous vein (GSV) graft

CASE REPORT
may be from the anastomosis and reflect leaking of blood outside the lumen peri operatively as a result of surgical technique or occur later as a complication of infection. 8In the presence of infection, it leads to rupture and fatal hemorrhage. 2 In our case, bleeding at the surgical site of the AV fistula suddenly occurred without any history of previous trauma.On physical examination at the AVF site, the patient's wound appeared swollen and wet, accompanied by necrotic tissue and pus.There is also pulsatile bleeding from the surgical wound.The presence of infection post-operatively can hinder the healing process of the surgical wound.The patient was then treated with a pressure bandage on the bleeding arm to stop the bleeding.The use of tourniquets at the upper lesion of the wound as a bleeding inhibitor is still a matter of debate.Although it can effectively reduce bleeding, the side effects of using a tourniquet can aggravate patients.Ischemia-reperfusion injury, skeletal muscle injury, and associated secondary end organ damage can occur following revascularization of a limb following prolonged tourniquet-induced ischemia.Activation of inflammatory responses systemically often leads to a complex cytokine cascade or storm that perpetuates inflammatory reactions in remote organs, which can clinically manifest as multiple-organ dysfunction. 13he patient was administered intravenous fluids to prevent shock due to profuse bleeding.Administration of intravenous infusion of crystalloid solutions (e.g., normal saline or lactated Ringer's) is purposed to support blood pressure.Before blood products are administered, up to 2-3 L of the crystalloid solution may be given.Insert two or more large-bore (≥16-gauge) intravenous catheters.If the patient is in a state of shock,  (Fig. 1) taken from the patient's right leg.
The GSV is trimmed according to the damaged blood vessel tissue size, then sutured continuously until the entire arterial tissue is completely covered.The tourniquet was removed, and no leakage was found in the suturing of this patch.
The wound was cleaned with saline, and minimal bleeding was controlled.The patient's postoperative 30-day follow-up went well, and there was no sign of complication, such as pain, infection, paresthesia, bleeding at the surgical site or ischemia in the distal forearm.

DISCUSSION
Acute blood loss through vascular access can be a life-threatening problem.Blood loss through AVF can be from aneurysms, stenosis and subsequent rupture, infection or trauma. 6In our center, we found that 2.86% (65 patients) out of 2273 patients from 2018 to 2020 who underwent AV fistula procedures had a pseudo aneurysm complication.A full-thickness tear or laceration of an artery initiates a pseudo aneurysm in AVF.Histologically, the internal elastic lamina is absent, and only adventitia is present. 7Pseudo aneurysms pairing two infusion lines simultaneously is recommended. 11At the time of insertion of an iv catheter, it is advisable to check the complete blood count so that blood can be prepared if there is a decreasing hemoglobin level. 11The use of tranexamic acid (TXA) as a bleeding inhibitor has been studied in cases of acute bleeding.The mechanism of TXA in trauma patients with significant hemorrhaging was the inhibition of fibrinolysis, leading to improved hemostasis. 14Research by The CRASH-2 collaborators showed that administering tranexamic acid in acute bleeding can reduce the risk of mortality in patients.Administration of 1 gram of tranexamic acid in the first 3 hours after bleeding occurs is more beneficial because it reduces massive blood loss and reduces the risk of early coagulopathy due to bleeding that occurs. 15n emergency cases, the option of immediate surgery is necessary.Ligating blood vessels may be considered to reduce and control bleeding that can be life-threatening.Another option is to perform open vascular reconstruction and salvage the created AVF. The option to use an endovascular technique is contraindicated in the presence of infection. 2n this case, open vascular reconstruction surgery was performed to salvage fistula access to hemodialysis.Unfortunately, the patient's cephalic vein tissue was completely damaged, then the goal of surgery was to improve the function of the brachial artery.Primary surgical repair and interposition vein grafting are recommended, especially with arterial defects over 1 cm.Arterial resection with end-to-end anastomosis can be done if the resection of the pathologic zone can be limited to 3 cm. 7In our case, the part of the damaged vessel was 3 cm in length with the edges of the vessel tissue being frail due to infection and necrosis.After trimming to remove damaged and fragile arterial tissue, the missing arterial tissue reached 4.5 cm, so it was decided to use the vein patch plasty technique.The autologous vein we use is the Great Saphenous Vein (GSV).The great saphenous vein patch is suitable for this surgery because it is proper by the vein's diameter, length and thickness, and the use of autogenous material plays an important role in reducing the risk of infection. 16Serkan et al. said there is a rule of thumb in harvesting GSV.The length of the harvested GSV is equal to 2 times the length of the blood vessel to be reconstructed. 17

CONCLUSION
Damage of the AV fistula made for hemodialysis access is a disadvantage for the patient considering this access is intended for life support, and complications that arise after that are life-threatening.Optimal treatment for the patient's life and hemodialysis access is a top priority.A good assessment of the condition of AVF and the choice of subsequent therapy greatly affect the patient's prognosis.