In the absence of concomitant infection, this may support an initial diagnostic assessment followed by treatment of any underlying venous outflow or central venous stenoses that may have caused the aneurysm or pseudoaneurysm [123]. Endovascular occlusion of the hemodialysis access using vascular plugs has also been suggested as a potential treatment for patients with aneurysm or pseudoaneurysm formation who are at-risk for rupture and who are poor surgical candidates [128]. Surgical Consultation Surgical management may be helpful in the setting of abnormal skin changes associated with the hemodialysis access cannulation site. Significant risk of life-threatening infection, rupture, and bleeding exists when abnormal skin changes are seen, including marked thinning, ulceration, eschar formation, spontaneous bleeding, pseudoaneurysm formation, superficial, or deep infection [129-132]. The presence of skin erosion or active hemorrhage from an AV access in the setting of a pseudoaneurysm is a surgical emergency that necessitates prompt recognition and definitive management. The treatment of an AVG pseudoaneurysm routinely involves placement of an interposition prosthetic graft which is tunneled in situ or extra-anatomically depending on the presence of a vascular access site infection [5]. Placement of a New Tunneled Dialysis Catheter In the setting of abnormal skin changes associated with the hemodialysis access cannulation site, the placement of a new tunneled dialysis catheter may be indicated as a bridging therapy, allowing for hemodialysis access while the patient undergoes surgical evaluation. If there is clinical concern for a systemic infection or bacteremia, treatment of the underlying infection should be initiated prior to the placement of a new tunneled dialysis catheter. A temporary nontunneled dialysis catheter can be placed for immediate hemodialysis access, while treatment of the infection is initiated.
Dialysis Fistula Malfunction. In the absence of concomitant infection, this may support an initial diagnostic assessment followed by treatment of any underlying venous outflow or central venous stenoses that may have caused the aneurysm or pseudoaneurysm [123]. Endovascular occlusion of the hemodialysis access using vascular plugs has also been suggested as a potential treatment for patients with aneurysm or pseudoaneurysm formation who are at-risk for rupture and who are poor surgical candidates [128]. Surgical Consultation Surgical management may be helpful in the setting of abnormal skin changes associated with the hemodialysis access cannulation site. Significant risk of life-threatening infection, rupture, and bleeding exists when abnormal skin changes are seen, including marked thinning, ulceration, eschar formation, spontaneous bleeding, pseudoaneurysm formation, superficial, or deep infection [129-132]. The presence of skin erosion or active hemorrhage from an AV access in the setting of a pseudoaneurysm is a surgical emergency that necessitates prompt recognition and definitive management. The treatment of an AVG pseudoaneurysm routinely involves placement of an interposition prosthetic graft which is tunneled in situ or extra-anatomically depending on the presence of a vascular access site infection [5]. Placement of a New Tunneled Dialysis Catheter In the setting of abnormal skin changes associated with the hemodialysis access cannulation site, the placement of a new tunneled dialysis catheter may be indicated as a bridging therapy, allowing for hemodialysis access while the patient undergoes surgical evaluation. If there is clinical concern for a systemic infection or bacteremia, treatment of the underlying infection should be initiated prior to the placement of a new tunneled dialysis catheter. A temporary nontunneled dialysis catheter can be placed for immediate hemodialysis access, while treatment of the infection is initiated.