Patient with loop-configuration PTFE hemodialysis graft presents with severe pain and ecchymosis of her left forearm

1. Patient with loop-configuration PTFE hemodialysis graft presents with severe pain and ecchymosis of her left forearm Earlier today the dialysis nurse had difficulty when cannulating the arterial limb of her graft

2. Active extravasation from the arterial limb due to traumatic needle cannulation

3. 9 Fr. introducer sheath stent graft (7mm) Using an angioplasty balloon to seal the ends of a 7mm x 4cm stent graft

4. Following deployment of stent graft

5. The patient also had a venous anastomotic stenosis

6. Pre-PTA Post-PTA

7. Duplication of left basilic veins

8. Left central veins

9. Patient returns three weeks later with development of small pseudoaneurysm arising from venous limb; the previous site of insertion of 8 Fr vascular sheath

10. pseudoaneurysm

11. pseudoaneurysm venous stenosis pseudoaneurysm

12. The development of the small pseudoaneurysm is likely due to continued elevation of intragraft pressure from the persistent venous anastomotic stenosis. The pseudoaneurysm is located at the site of insertion of the large diameter (8 Fr) vascular sheath which was used during insertion of the stent graft for repair of the acute injury in the arterial limb of the graft. The patient is schedule to undergo surgical revision of the venous anastomotic stenosis in 9 days. this should reduce the intragraft pressure and remove the impetus for further enlargement of the pseudoaneurysm