Caractheristic of Pseudoaneurysm Patients With Hemodialysis vascular

Access at Saiful Anwar Hospital in January 2014 July 2017

Wanda Gusta Rai1, Artono Isharanto2, Koernia Kusuma Wardhana3
1
General Surgery Resident of Brawijaya university
2
Thorac, Cardiac and Vascular Surgery Consultant of Brawijaya University
3
Thorac, Cardiac and Vascular Surgery Consultant of Brawijaya University

OBJECTIVE
Along with the incidence of Chronic Renal Failure which is increasing, the need for venous
access for hemodialysis are also getting bigger. Venous access for Hemodialysis, can be done
conventionally or by making A-V Shunt. In the long-term use in the AV-shunt can cause
problems such as pseudoaneurysm.
MATERIALS AND METHOD
This study is a Retrospective study. Data is taken from the patient's medical records in the
Vascular and Endovascular Divisions of the Department of Surgery Saiful Anwar Hospital
January 2014 - July 2017. Data processing was performed with SPSS 16.0.
RESULTS
From 148 research subjects studied, male patients 52%, while female 48%. There were 25.7%
people in the age category <40 years, 55.4% people in the age category 40-60 years, 18.9%
people age >60 years. The main causes of renal failure are diabetes mellitus 42.6%, hypertension
35.8%, kidney stones 13.5%, genetic 5.4%, and autoimmune 2.7%. The location of
pseudoaneurysm on the left wrist 31.1%, left cubiti 35.8%, right wrist 4.7% and others 28.4%.
For the duration of pseudoaneurysm, the results were 11.5% <12 months, 20.9% 12-24 months,
and 67.6% >24 months.
CONCLUSSIONS
Most of pseudoaneurysm patients are at age over 40 years and the most common risk factors are
diabetes mellitus. The most common location of pseudoaneurysm is in the left wrist region. A
good care vascular access of hemodialysis is necessary in order to avoid complications.

Keyword: Chronic Renal Failure, Haemodyalisis Vascular access, Pseudoaneurysm.

INTRODUCTION

Along with the incidence of Chronic Renal Failure which is increasing, the need for
venous access for hemodialysis are also getting bigger. End-stage renal disease is becoming
increasingly common in the United States with an aging population. Data from the U.S. Renal
Data System in 2005 indicated that more than 106.000 new patients began treatment for endstage
renal disease, and that approximately 341.000 patients were receiving dialysis. 1 Data in 2012, the
number of kidney failure patients in Indonesia about 150.000 people, and about 10.000 patients
were undergoing to hemodialysis.10 To ensure adequate haemodialysis treatments, a well-
functioning vascular access (VA) is a prerequisite in dialysis patients. 2
It is necessary to make vascular access which enables the hemodialysis process to be
performed. There are two kinds of vascular access to hemodialysis. Long term vascular access is
sometimes referred to as permanent vascular access and temporary vascular access using a
venous catheter. Long term use of this vascular access can cause problems such as
pseudoaneurism or false aneurysms.2
Pseudoaneurysm (or false aneurysm) is a pulsatile haematoma that may be formed by
hemorrhage in soft tissues. It has a fibrous encapsulation and a communication between the
ruptured vessel and the fluid space.3 Pseudoaneurysm (PSA) formation is also known
complication of hemodialysis vascular access, which is associated with an increased risk of
thrombosis, bleeding, infection, pain, and failure of attempted hemodialysis. 4 This complication
are common and represent a major cause of hospitalization in haemodialysis patients with 36-
39% of admissions related to dialysis access.2
The various conditions and complications of the disease can affect the AV-Shunt both
before and after surgery, therefore the nurse hemodialysis plays an important role ranging from
suggesting and motivating patients to AV-Shunt, providing adequate information about AV-
Shunt, overcoming and observing the sharing of complications during the use of AV -Shunt and
of course maintain AV-Shunt as long as AV-Shunt is used. This study aims to determine the
characteristics of pseudoaneurysm patients with hemodialysis vascular access at Saiful Anwar
Hospital in January 2014 July 2017.

.
MATERIALS AND METHOD

This study is a Retrospective study. The population in this study were all patients
treated in the Vascular and Endovascular Divisions of the Department of Surgery Saiful Anwar
Hospital January 2014 - July 2017. Number of samples are 148 patients, with the inclusion
criteria are pseudoaneurysmic patients who had hemodialysis vascular access installed.
Exclusion criteria are patients with complications before the installation of hemodialysis vascular
access. Data is taken from the patient's medical records with ICD-10 diagnostic of
pseudoaneurysm patients at Saiful Anwar Hospital in January 2014 July 2017. Data processing
was performed with SPSS 16.0.

RESULT
In this study there are 148 respondents of pseudoaneurysm patients who had
hemodialysis vascular access installed. All patients treated in the Vascular and Endovascular
Divisions of the Department of Surgery Saiful Anwar Hospital January 2014 - July 2017. Below
is a table of respondent characteristics based on gender and age in patients.

Table 1. Characteristics of Respondents Based on Gender and Age in Pseudoaneurysm Patients with Installed
Hemodialysis Vascular Access in Saiful Anwar Hospital at January 2014 - July 2017.

Characteristics of respondents Frequency (%)

Gender
Male 77 52%
Female 71 48%

Age (years)
<40 38 25.7%
40-60 82 55.4%
>60 28 18.9%
Based on Table 1. Most the types gender of pseudoanerysm patients are male (52%), while
female (48%). Based on the age, most of pseudoaneurysm patients are at range of 40-60 years
(55.4%), there were 25.7% people in the age category <40 years and 18.9% people age >60
years.
Table 2. Frequency Distribution the risk factor of Renal Failure

Risk Factor of Renal failure Frequency (%)

Diabetes Mellitus 63 42.6%

Hypertension 53 35.8%
Kidney Stones 20 13.5%
Genetic 8 5.4%
Autoimmune 4 2.7%

Based on Table 2. The main causes of renal failure are diabetes mellitus (42.6%), next
hypertension (35.8%), kidney stones (13.5%), genetic (5.4%), and autoimmune (2.7%).

Table 3. Characteristic of Pseudoaneurysm Based on Location and Duration in Patients with Installed
Hemodialysis Vascular Access in Saiful Anwar Hospital at January 2014 - July 2017.

Characteristic of pseudoaneurysm Frequency (%)

Location
Left wrist 46 31.1%
Left cubiti 53 35.8%
Right wrist 7 4.7%
Others 42 28.4%

Duration (Months)
0-12 17 11.5%
12-24 31 20.9%
>24 100 67.6%
Based on table 3. The most common location of pseudoaneurysm is on the left cubiti (35.8%),
next on the left wrist (31.1%), right wrist (4.7%) and others (28.4%). While the duration of
pseudoaneurysm, most common happened >24 months (67.6%).

DISCUSSION
Chronic renal failure is a decline of renal function that progressive and permanent
which can be caused by various kinds of disease. Diabetes mellitus is one of the most common
diseases cause terminal renal failure, followed by hypertension.9 To ensure adequate
haemodialysis treatments, a well-functioning vascular access (VA) is a prerequisite in dialysis
patients.2 Vascular access allows the blood to flow in large quantities and continuously into the
machine during the hemodialysis process. In normal venous blood vessels it is unlikely that this
happens because the blood vessels will collapse when blood is drawn through the machine. It is
necessary to make vascular access which enables the hemodialysis process to be performed.
Long term use of this vascular access can cause problems such as pseudoaneurism or false
aneurysms.2
A focal vessel dilatation arising from an arteriovenous access could be either a true
aneurysm or a pseudoaneurysm. A true aneurysm is a vascular dilatation containing all its wall
layers intact. Conversely, a pseudoaneurysm is a dilatation with disruption of 1 or more layers of
its wall. A pseudoaneurysm wall typically contains neointima and fibrous tissue and sometimes
is lined with thrombus.5 They can be either congenital or acquired (mycotic, syphilitic, traumatic,
collagen disease). Most They can be central (aortic,carotid) or peripheral (bracial, femoral,
popliteal). Most peripheral aneurysms are pseudoaneurysms produced due to local arterial
damage either by diagnostic and therapeutic arterial chateterizations or by direct trauma to the
arterial site, both leading to disruption of wall continuity and bleeding into the surrounding tissue
where the circulating blood is held by the adjancent tissues, fascia and thrombus and not by the
normal arterial wall. The usual presentation is a painless, pulsatile, asymptomatic mass usually
incidentally diagnosed. However, it does become symptomatic when complications arise, such as
disruption causing profuse bleeding and vascular collapse or thrombosis in the sac, which throws
emboli into peripheral circulation.6 This condition can manifest as a mass throbbing, audible
bruit, and can be felt thrill at the time of palpation.7
 Based on the the patient's medical records in the Vascular and Endovascular Divisions
of the Department of Surgery Saiful Anwar Hospital January 2014 - July 2017, most the types
gender of pseudoanerysm patients are male (52%), gender is one of the risk factors which can
not be modified.8 Based on age, the most of pseudoaneurysm patients are at range of 40-60 years
(55.4%), this range age belongs to the elderly category. The old age became one of the
independent predictors of increased risk of bleeding or complications vascular. 8
Based on the result. the most common location of pseudoaneurysm is on the left cubiti
(35.8%), next on the left wrist (31.1%), right wrist (4.7%) and others (28.4%). A major cause of
brachial artery pseudoaneurysm is inadvertent arterial puncture during venous cannulation for
hemodialysis. Factors that contribute to this complication are use of large-caliber needles, poor
puncture technique, and premature puncturing of the fistula after surgery. Other reported causes
of brachial artery pseudoaneurysms include penetrating and blunt trauma, catheterization for
vascular intervention, drug abuse, and arterial gas sampling. 5 While the duration of
pseudoaneurysm, most common happened >24 months (67.6%).
Diagnosis of a pseudoaneurysm can be performed by arterial doppler ultrasonography,
contrast-enhanced computed tomography angiography, and magnetic resonance. The Doppler
ultrasonography will show the presence of blood flow or thrombus within the pseudoaneurysm,
the size of the neck of the pseudoaneurysm, the integrity of the adjacent vessels, and the presence
of loculations. Moreover, this method is faster, less expensive and more available in medical
institutions.3
Treatment for hemodialysis access aneurysms and pseudoaneurysms include open
surgical and percutaneous techniques. Until recently, the standard therapy for aneurysms was
open surgical repair with excision or ligation of the pseudoaneurysm, followed by interposition
grafting with a prosthetic conduit. Open surgery typically is performed in cases of access rupture
and infection. Percutaneous treatments are intended to maintain patency and function of the
existing access while excluding the aneurysm or pseudoaneurysm from the circulation.
Percutaneous treatments include endovascular stent or covered stent implantation, coil
embolization, and ultrasound-guided thrombin injection. The most appropriate treatment must be
selected according to the cause, location, size, and accessibility of the pseudoaneurysm. 5
CONCLUSION
A major cause of pseudoaneurysm is inadvertent arterial puncture during venous
cannulation for hemodialysis. Furthermore, as it is a slow progressive condition it is imperative
to care or maintain the vascular access as long as is used and diagnose it as soon as possible in
order to prevent complications as well as the risk of infection of the afflicted limb. The
developments in treatment procedures and the importance of sustained vascular access for
hemodialysis will be rising the survival rates in patients with end-stage renal disease.
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