Disrupted anastomotic pseudoaneurysm in arteriovenous grafts: an etiology-driven case series with a proposed preliminary management framework.

BACKGROUND

Disruption of an anastomotic pseudoaneurysm in an arteriovenous graft (AVG) is a rare but life-threatening complication in hemodialysis patients, distinct from the more common graft-body pseudoaneurysms caused by repeated needle puncture. A systematic management framework for this specific entity is currently lacking.

OBJECTIVE

To propose a preliminary etiology-based diagnostic and therapeutic conceptual framework for AVG anastomotic rupture through the analysis of three cases with different underlying mechanisms, and to explore its clinical applicability.

METHODS

We retrospectively analyzed the clinical data, imaging findings, surgical findings, and outcomes of three patients with AVG anastomotic rupture caused by trauma, degenerative changes, and infection, respectively. Based on a review of the literature, we constructed an etiology-based diagnostic and therapeutic decision-making framework grounded in a three-dimensional "localization-characterization-condition" assessment.

RESULTS

All three patients presented with pulsatile masses in the anastomotic region, and imaging studies confirmed pseudoaneurysm formation with anastomotic disruption. Individualized surgical strategies were adopted based on intraoperative etiology: direct repair was performed for traumatic rupture; autologous vein interposition grafting was employed for mechanical rupture due to tissue edema and friability; and for infectious rupture, extensive debridement combined with direct repair and complete AVG excision was undertaken. All patients recovered uneventfully and were transitioned to temporary or long-term dialysis catheters.

CONCLUSION

This preliminary framework suggests a stepwise approach to decision-making regarding treatment objectives, surgical modalities, and key technical details within a stepwise framework of emergent control versus elective planning. It highlights the potential importance of etiological prevention and correct intraoperative decision-making, and may offer a practical reference for clinical management. Further multicenter studies are required to validate its generalizability.