It’s been a year and a half since put out the call for cases for a compendium of point of care ultrasound topics for nephrologists in collaboration with The POCUS Journal. We had an overwhelming response from the nephrology community with dozens of excellent submissions, the vast majority of which were written by nephrology fellows. Thank you for all who wrote and reviewed for us, you really made a difference for nephrology fellows and the broader POCUS community! Over the coming weeks, we want to share with you the fruits of this collaboration.
First, we’d like to share an unusual presentation of a dysfunctional hemodialysis vascular access. A 44-year-old man presented to the emergency department with 5 days of swelling and pain to his arteriovenous graft. He was afebrile and exam revealed only erythema, swelling, and tenderness to the left upper extremity with intact bruit and thrill to the graft. Greyscale and color Doppler point of care ultrasound using a linear transducer revealed 2 pseudoaneurysms of the graft not identified on physical exam due to pain (figure 1), as well as cobblestoning suggestive of cellulitis overlying the graft (figure 2).
Figure 1: Color Doppler ultrasound still image of the AV graft at the pseudoaneurysm neck (arrow). Note the color flow present within the body of the pseudoaneurysm (arrowhead) better seen on the video.
Figure 2: Color Doppler imaging demonstrating cobblestoning (greyscale at arrow) overlying a normal segment of arteriovenous graft (with color flow). Note the alternating areas of light and dark with the appearance of a pre-modern city street.
On revealing this information, the patient noted focal swellings that formed up after the most recent hemodialysis session. The patient was treated with antibiotics. Vascular surgery was consulted and excised the graft promptly after pre-operative CT. Pseudoaneurysms are seen infrequently in AV grafts, leading to only 3% of failures compared with 13% of AV fistula failures. While stent grafts can be used, excision is required in cases of infected grafts. For more on POCUS of the hemodialysis vascular access, visit the review by Larissa Kruger Gomes in The POCUS Journal Kidney Edition.
Nathaniel Reisinger & Abhilash Koratala
Edited by: Sam Kant, Matt Sparks