Characteristics of Vascular Access Cannulation Complications in End Stage Kidney Disease Patients in West Java from 2018 to 2022: A Retrospective Observational Study

Figures & data

Figure 1 The flowchart of the study selection process.

Figure 2 Clinical pictures of the cannulation complications from vascular access in ESKD patients: (A) Giant draining vein shown as a long pulsatile mass in the draining vein; (B) Ruptured pseudoaneurysm covered with a blood crust; (C) Impending rupture pseudoaneurysm with tense and glistening skin; (D) Pseudoaneurysm shown as a pulsatile mass without pain or bleeding; (E) Hematoma with bruise.

Table 1 Marfen and Hapsari Criteria for Cannulation Complications from Vascular Access in End-Stage Kidney Disease (ESKD) Patients

Criteria	Giant Draining Vein	Hematoma	Ruptured Pseudoaneurysm	Impending Ruptured Pseudoaneurysm	Pseudoaneurysm
Risk factors	- Recurrent hemodialysis needle puncture at the same site - Skin infection - Accidental arterial puncture - Inadequate pin point pressure after hemodialysis cannulation
Clinical findings	Long pulsatile mass in the draining vein	Non-pulsatile mass with bruise surrounding the vascular access	Painful pulsatile mass, with active bleeding, might be covered with dried blood crust	Painful pulsatile mass, without active bleeding, with tense and glisten skin	Pulsatile mass without pain or bleeding
Ultrasound	A substantial draining vein dilatation with a diameter greater than 2 cm.	Acute hematoma without visible internal blood flow during color Doppler ultrasound.	The yin-yang sign on Doppler ultrasound denotes bidirectional flow as a result of the blood swirling within the pseudoaneurysm.

Figure 3 Ultrasound of the cannulation complications from vascular access in ESKD patients: (A) Giant draining vein shown as an enlarged draining vein more than 2 cm in diameter; (B) Acute hematoma visible as hypoechoic appearance without internal blood flow during color Doppler; (C) The yin-yang sign on Doppler ultrasound within the pseudoaneurysm.

Figure 4 The Marfen and Hapsari flowchart of the surgical procedure for cannulation complications from vascular access in ESKD patients.

Table 2 Characteristics of Research Subjects

Variable		Proportion (%)
Age	Mean	46.1 ± 13.41 years
	Median	46 years
	Minimum	11 years
	Maximum	82 years
Sex	Man	52 (43%)
	Woman	69 (57%)
End-stage kidney disease Duration	Mean	25.02 ± 31.3 months
	Median	10 months
Risk for End-stage kidney disease	Hypertension	95 (78.5%)
	Diabetes	6 (5%)
	Hypertension and Diabetes	14 (11.7%)
	Congenital anomalies of the kidney and urinary tract (CAKUT)	1 (0.8%)
	Nephrolithiasis	1 (0.8%)
	Polycystic kidney disease	1 (0.8%)
	Preeclampsia	1 (0.8%)
	Post-Partum Cardiomegaly (PPCM)	1 (0.8%)
	Pyelonephritis	1 (0.8%)
Hemodialysis	Once a week	9 (7.4%)
	Two times a week	105 (86.8%)
	Three times a week	7 (5.8%)
Subjective symptoms	Bleeding from the mass	67 (55.4%)
	Painful mass	108 (89.2%)
	Bulging mass	121 (100%)
Vascular access	Arteriovenous Fistula	89 (73.6%)
	Common femoral vein	32 (26.4%)
Diagnosis	Arteriovenous fistulas cannulation
	- Giant draining vein	1 (0.8%)
	- Ruptured pseudoaneurysm	58 (47.9%)
	- Impending ruptured pseudoaneurysm	19 (15.7%)
	- Pseudoaneurysm	11 (9.1%)
	Common femoral vein cannulation
	- Ruptured pseudoaneurysm	6 (5%)
	- Impending ruptured pseudoaneurysm	9 (7.4%)
	- Pseudoaneurysm	10 (8.3%)
	- Hematoma	7 (5.8%)
Location	Right Upper Arm	1 (0.8%)
	Left Upper Arm	10 (8.3%)
	Right Antecubital Fossa	2 (1.7%)
	Left Antecubital Fossa	32 (26.4%)
	Right Forearm	11 (9.1%)
	Left Forearm	33 (27.3%)
	Right Femoral	15 (12.4%)
	Left Femoral	17 (14%)
Hemoglobin level	Mean	7.27 ± 1.91 g/dL
	Median	7.1 g/dL
	Minimum	2.0 g/dL
	Maximum	12.0 g/dL
Leucocyte count	Mean	11,616 ± 6167 /μL
	Median	10,100 /μL
	Minimum	2140 /μL
	Maximum	40,220 /μL
Surgical procedure	Vein ligation	1 (0.8%)
	Hematoma evacuation	6 (5%)
	Draining vein repair	4 (3.3%)
	Draining vein ligation	47 (38.8%)
	Arterial ligation	10 (8.3%)
	Arterial bypass with vein graft	7 (5.8%)
	Arterial patch repair	18 (14.9%)
	Arterial primary repair	28 (23.1%)
Vascular mass diameter	Mean	5.42 ± 3.38 cm
	Median	4.0 cm
	Minimum	1 cm
	Maximum	20 cm
Vascular defect	Mean	8.79 ± 10.09 mm
	Median	8.0 mm
	Minimum	0 mm
	Maximum	100 mm
Hematoma volume	Mean	87.93 ± 20 cc
	Median	20 cc
	Minimum	5 cc
	Maximum	1200 cc

Table 3 ANOVA Analysis Between Diagnosis and Mean Differences of Subjective Symptoms (Days)

Diagnosis	Mean of Bleeding from the Mass (p = 0.001)	Painful Mass (p = 0.110)	Bulging Mass (p = 0.001)
Giant draining vein	0	0	365
Hematoma	3.14 ± 5.42	6.29 ± 4.23	6.0 ± 4.24
Ruptured Pseudoaneurysm	2.14 ± 2.14	10.19 ± 10.77	20.03 ± 23.57
Impending Ruptured Pseudoaneurysm	0	21.79 ± 31.12	26.79 ± 35.49
Pseudoaneurysm	0	14.10 ± 26.57	40.29 ± 33.15

Notes: A p value < 0.05 (bolded) indicates significant differences. The variables with zero (0) values were treated as missing values and excluded from the analysis.

Table 4 ANOVA Analysis Between Diagnosis and Mean Differences of Hemoglobin and Leucocytes

Diagnosis	Mean of Hemoglobin (p = 0.001)	Mean of Leucocytes (p = 0.444)
Giant draining vein	12 ± 0	6070 ± 0
Hematoma	7.28 ± 2.25	11,460 ± 3337
Ruptured Pseudoaneurysm	6.69 ± 1.74	12,082 ± 6997
Impending Ruptured Pseudoaneurysm	8.08 ± 1.81	12,300 ± 5488
Pseudoaneurysm	7.71 ± 1.79	9602 ± 4776

Note: A p value < 0.05 (bolded) indicates significant differences.

Table 5 ANOVA Analysis Between Surgical Procedure and Mean Differences of Vascular Mass Diameter, Vascular Defect, and Hematoma Volume

Surgical Procedure	Mean of Vascular Mass Diameter in Centimeter (p = 0.002)	Mean of Vascular Defect in Millimeter (p = 0.001)	Mean of Hematoma Volume in Milliliter (p = 0.001)
Vein ligation	10 ± 0	10 ± 0	200 ± 0
Hematoma evacuation	7.83 ± 3.43	0.33 ± 0.81	366.67 ± 437.79
Draining vein repair	5.0 ± 3.91	8.5 ± 8.58	60.0 ± 93.45
Draining vein ligation	4.06 ± 1.81	9.85 ± 4.17	30.32 ± 33.85
Arterial ligation	4.0 ± 1.24	12.6 ± 7.12	26.0 ± 27.86
Arterial bypass with vein graft	5.57 ± 2.76	27.14 ± 32.38	171.43 ± 366.62
Arterial patch repair	6.89 ± 4.62	9.33 ± 4.32	83.33 ± 77.0
Arterial primary repair	6.61 ± 4.10	2.5 ± 1.0	129.11 ± 151.53

Note: A p value < 0.05 (bolded) indicates significant differences.

Figure 5 Excised pseudoaneurysm and histological pictures of pseudoaneurysm and aneurysm: (A) An excised draining vein pseudoaneurysm; (B) Pseudoaneurysm histological examination showed a faint vascular appearance with numerous necrotic cells, hemosiderin deposits, macrophages, and stromal fibro-collagen tissue partially hyalinized with massive scattering of inflammatory cells, including lymphocytes, polymorphonuclear leukocytes, and eosinophils; (C) Aneurysm histological examination showed the tunica intima with a completely erosive endothelium and a fibro-collagenous fibrous connective tissue stroma covered with inflammatory cells, lymphocytes, and histiocytes; the tunica media is composed of partially fibrotic muscle cells with a normal nucleus; and the tunica serosa consists of connective tissue accompanied by mature adipose tissue with a normal nucleus.

Figure 6 Cannulation of the AVF and the CFV: (A) The cannulation of the AVF, the outflow (red) placed on the proximal draining vein, and the inflow (blue) placed on the distal draining vein; (B) The cannulation of the CFV, the outflow (red) placed on the CFV, and the inflow (blue) placed on the cephalic vein.