Hemodialysis Access, Case 5. Ken U. Ekechukwu, MD, MPH, FACP.

Clinical problem: 44-year-old man who had had multiple failed arteriovenous accesses in the past. His new left forearm non-autogenous brachiobrachial access did not work well at his most recent hemodialysis session.

Findings at imaging: The angiogram shows a loop arteriovenous graft connecting the distal left brachial artery to the proximal left brachial vein. The artery, the graft, and the vein are patent, the vein yet to mature. A large aneurysm overlays the distal left brachial artery, obscuring the arterial anastomosis of the graft and the effect of the aneurysm, if any, on the juxta-anastomotic graft. Axial color Doppler view of the aneurysm confirms a massive, swirling structure with a turbulent interior. The arrow at its 11:00 position identifies the juxta-anastomotic segment of the graft, partially collapsed by the aneurysm.

Intervention: The patient was referred to vascular surgery for aneurysmectomy, which corrected the problems at dialysis. The mass proved to be a pseudoaneurysm of the distal brachial artery thought to be iatrogenic.