URGENT SURGICAL REPAIR OF AN EXPANDING ARTERIOVENOUS FISTULA PSEUDOANEURYSM IN A PATIENT WITH MODERATE DILATED CARDIOMYOPATHY: A CASE REPORT

Abstract

Background: Arteriovenous fistula (AVF) pseudoaneurysms are critical complications demanding immediate evaluation. It is a medical emergency requiring prompt management, as conservative measures are inadequate for rapidly expanding masses due to the high risk of fatal haemorrhage.

Case description: A 54-year-old female presented to the emergency department with left arm pain and a rapidly enlarging 6 × 4 cm pulsatile mass over approximately one week. A functional AVF had been created 13 years prior. Point-of-care duplex ultrasonography confirmed a large pseudoaneurysm sac with active arterial inflow. Moderate dilated cardiomyopathy (ASA Physical Status Class III) necessitated rigorous preoperative multidisciplinary optimisation. Intraoperatively, temporary vascular control was achieved using proximal and distal sutures, supplemented by a sterile gauze tourniquet. The pseudoaneurysm sac was entirely excised, and the arterial defect was closed via direct suturing. Permanent AVF ligation was performed due to local tissue compromise, and a pre-existing mature AVF in the contralateral right arm was immediately utilised for subsequent haemodialysis sessions. Postoperatively, the distal limb remained well-perfused with no clinical signs of acute ischaemia. During the early post-operative follow-up on day 9, the wound exhibited delayed healing with the surgical drain still in situ, after which the patient defaulted on scheduled appointments (lost to follow-up).

Conclusion: Symptomatic and rapidly enlarging AVF pseudoaneurysms may require prompt surgical assessment because of the risk of rupture. In this case, definitive surgical management was successfully performed despite significant cardiovascular comorbidity, with multidisciplinary perioperative management. Early postoperative follow-up showed delayed wound healing, but further assessment was limited by the patient’s subsequent loss to follow-up.