Abstract
Objectives: Infection of an arteriovenous fistula (AVF) for hemodialysis is a relatively rare complication. When such an infection is localized without sepsis, it responds well to antibiotic treatment. However, if rupture and hemorrhage occur as a result of such an infection, an emergency operation is required. In the present study, we investigated the pathology of rupture of an infected AVF as well as treatment options in 6 cases of rupture secondary to AVF infection encountered at our institution.
Patients and methods: All patients were women with a mean age of 70.5 years. Five were referred to our hospital due to hemorrhage, while the other was admitted for an infected pseudoaneurysm.
Results: The duration from AVF formation to infection and rupture was an average of 25.0 months. Two of the 6 patients experienced rupture within 2 months after AVF creation, while all received emergency surgery. In the cases of open hemorrhage, they transferred to the operating room applying a tourniquet to their arm. Four had a rupture in the outflow vein or mid-AVF. In those cases, the infected portion was removed and the AVF was closed surgically. In 2 of those cases, the surgical wound was closed using a 1-step procedure and it was left as an open wound in the other 2. Anastomotic hemorrhage occurred in 2 patients. In 1 of those, the ruptured portion was first sutured in an attempt to preserve the AVF, though AVF closure was eventually necessary, as hemorrhage immediately recurred, while in the other the infected portion was removed, then the AVF was closed and the radial artery reconstructed using the autogenous vein. In that second case, the reconstructed graft collapsed as a result of relapsing infection, thus it was necessary to ligate the radial artery, which was only required in this case. Blood culture findings confirmed MRSA in 5 cases. Four of the 6 patients survived. One of the 2 who underwent 1-step wound closing died from sepsis induced by recurrent infection and the other death was from aggravation of general status caused by difficulties with hemodialysis treatment after surgery.
Conclusion: S. aureus is frequently found to be a causative bacterium of AVF infection. It is critical to control the hemorrhage of the ruptured AVF in the initial step of their treatment. For surgical treatment, it is generally considered necessary to open the infected wound, as 1-step wound closure has a risk of developing sepsis. In these cases, it is important to quickly design a therapeutic plan, including proper choice of antibiotics and operative procedure.
