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Aneurysmal degeneration of a hemodialysis arteriovenous fistula (AVF) is common; however, distal digital embolization from an AVF is extremely rare. Even though the ultimate fate of all arteriovenous hemodialysis access is thrombosis with minimal consequences, dislodgement of thrombus at the proximal anastomosis could lead to ischemia of the distal arterial circulation. We here present a case of a renal transplant patient with a thrombosed aneurysmal AVF who presented with acute digital ischemia successfully treated with combination catheter-directed thrombolysis and open repair. No similar report was found describing this entity treated with this approach.

Both physical examination (PE) and intra-access pressure (IAP) measurements have been used in the identification of stenosis in an arteriovenous access. The aim of this study was to evaluate the accuracy of PE and IAP in the diagnosis of arteriovenous fistula (AVF) stenosis. A total of 84 patients were enrolled in the study (54% men, mean age of 50.7 +/- 12.7 years and mean AVF patency of 24.9 +/- 7.8 months, 52% radiocephalic). Abnormalities of pulse and thrill were used as the diagnostic tools for the detection of stenosis using the physical examination. For IAP, stenosis was suspected when the ratio between IAP at the arterial puncture site and the mean blood pressure was 0.43. The diagnosis of stenosis was confirmed by Doppler ultrasound (DU). Sensitivity (S), specificity (SP), positive predictive value (PPV), negative predictive value (PNV), and accuracy were calculated for the two early detection tests. According to DU, 50 (59%) AVF were considered positive for the presence of stenosis. Fifty-six (66%) AVF were considered positive for the presence of stenosis by PE and 34 (40%) by IAP. S, SP, PPV, and NPV for PE and IAP were 96%, 76%, 86%, and 93% and 60%, 88%, 88%, and 60%, respectively. The accuracy for PE and IAP was 88% and 71%, respectively. PE proved to be an accurate method for the diagnosis of stenosis and should be part of all surveillance protocols of stenosis detection in AVF.