Characteristics of Vascular Access Cannulation Complications in End Stage Kidney Disease Patients in West Java from 2018 to 2022: A Retrospective Observational Study

Abstract

Background: End-stage kidney disease (ESKD) is associated with a tremendous financial burden. Data in Indonesia shows an increasing number of patients with ESKD taking hemodialysis as a routine procedure every year. Establishment and maintenance of vascular access are important in the management of ESKD. Vascular complications that often arise due to hemodialysis are common and one of the main reasons for hospitalization. Cannulation complications ranged from minor hematomas to acute bleeding from pseudoaneurysms that required emergency surgical procedures. This study aims to assess the different clinicopathological characteristics of ESKD patients with vascular access cannulation complications and the surgical management related to the complications.

Materials and methods: This research is a retrospective observational study. The research subjects in this study were ESKD patients in the vascular and endovascular surgery division of the tertiary hospital in West Java, Indonesia. There were 121 study subjects. Clinicopathological characteristics of vascular cannulation complications and surgical management are extracted from the medical record.

Results: Three major vascular complications were ruptured pseudoaneurysms 64/121 (52.9%), impending rupture pseudoaneurysms 28/121 (23.1%), and pseudoaneurysms 21/121 (17.4%). Common surgical procedures were ligation of the draining vein 47/121 (38.8%), arterial primary repair 28/121 (23.1%), and arterial patch repair 18/121 (14.9%). There was a significant relationship between symptoms of bleeding in ruptured pseudoaneurysms and bulging masses in pseudoaneurysms (p = 0.001). There was a significant relationship between the diameter of the vascular mass, vascular defect size, and hematoma and the type of surgical procedure taken (p < 0.010).

Conclusion: Ruptured, impending rupture, and pseudoaneurysms are major complications of vascular access in ESKD patients, and there was a significant relationship between the carried-out surgical procedure and the size of the vascular mass, defect, and hematoma.

Keywords: arteriovenous fistula; end-stage kidney disease; hemodialysis; pseudoaneurysm; vascular access.

Figure 1

The flowchart of the study selection process.

Figure 2

Clinical pictures of the cannulation complications from vascular access in ESKD patients: (A) Giant draining vein shown as a long pulsatile mass in the draining vein; (B) Ruptured pseudoaneurysm covered with a blood crust; (C) Impending rupture pseudoaneurysm with tense and glistening skin; (D) Pseudoaneurysm shown as a pulsatile mass without pain or bleeding; (E) Hematoma with bruise.

Figure 3

Ultrasound of the cannulation complications from vascular access in ESKD patients: (A) Giant draining vein shown as an enlarged draining vein more than 2 cm in diameter; (B) Acute hematoma visible as hypoechoic appearance without internal blood flow during color Doppler; (C) The yin-yang sign on Doppler ultrasound within the pseudoaneurysm.

Figure 4

The Marfen and Hapsari flowchart of the surgical procedure for cannulation complications from vascular access in ESKD patients.

Figure 5

Excised pseudoaneurysm and histological pictures of pseudoaneurysm and aneurysm: (A) An excised draining vein pseudoaneurysm; (B) Pseudoaneurysm histological examination showed a faint vascular appearance with numerous necrotic cells, hemosiderin deposits, macrophages, and stromal fibro-collagen tissue partially hyalinized with massive scattering of inflammatory cells, including lymphocytes, polymorphonuclear leukocytes, and eosinophils; (C) Aneurysm histological examination showed the tunica intima with a completely erosive endothelium and a fibro-collagenous fibrous connective tissue stroma covered with inflammatory cells, lymphocytes, and histiocytes; the tunica media is composed of partially fibrotic muscle cells with a normal nucleus; and the tunica serosa consists of connective tissue accompanied by mature adipose tissue with a normal nucleus.

Figure 6

Cannulation of the AVF and the CFV: (A) The cannulation of the AVF, the outflow (red) placed on the proximal draining vein, and the inflow (blue) placed on the distal draining vein; (B) The cannulation of the CFV, the outflow (red) placed on the CFV, and the inflow (blue) placed on the cephalic vein.