Pseudoaneurysm over Old Thrombosed Arteriovenous Fistulae Triggered by Sphygmomanometer Compression: Two Unusual Cases

Progressive exhaustion of vascular access sites often leads to complex lesions in long-term hemodialysis patients. In this setting, the occurrence of a pseudoaneurysm over long-thrombosed, non-functional fistulae is exceptionally rare. We report two cases of pseudoaneurysm formation developing several years after arteriovenous fistula (AVF) thrombosis, both seemingly triggered per dialysis by the use of a blood pressure cuff on the affected arm.

Case 1:

A 56-year-old woman with end-stage kidney disease (ESKD) on chronic hemodialysis since 2007 presented with painless swelling of the right arm immediately after her dialysis session, on the site of per-dialysis repeated blood pressure measurements. She had a history of vascular access exhaustion and had been dialyzed via a central venous catheter since 2023. The swelling corresponded to a long-thrombosed humero-cephalic prosthetic AVF (created in 2007, non-functional since 2020 after multiple endovascular revisions for recurrent thrombosis).

Imaging revealed a 7 cm partially thrombozsed pseudoaneurysm supplied by the distal humeral artery. Surgical exploration identified a disrupted humero-prosthetic anastomosis. Complete resection of the pseudoaneurysm and the old graft was performed, followed by artero-arterial interposition with a 5 mm PTFE graft to restore arterial continuity. Postoperative recovery was uneventful, with no ischemic or infectious complications.

Case 2:

A 58-year-old woman on maintenance hemodialysis since 2014  presented with an acute painful swelling of the left arm over a long-thrombosed humero-cephalic fistula (created in 2014, complicated by pseudoaneurysms in 2015 and 2016, and non-functional since 2019). The swelling developed at the site of repeated per dialysis blood pressure measurements. She had been dialyzed through a right-sided AVF since 2019. Duplex ultrasound and CT angiography demonstrated a partially thrombosed pseudoaneurysm without active flow, consistent with local rupture of a fibrotic venous segment. Surgical ligation of the feeding pedicle with hematoma evacuation was performed, leading to complete recovery.

Neither patient had undergone recent cannulation or developed infection at the affected site. In both cases, the only identifiable mechanical stress was repetitive sphygmomanometer cuff compression during blood pressure monitoring. The findings supported the hypothesis of cuff-induced /triggered  arterial micro-rupture in fragile segments of the AVF wall. In both cases, surgical exploration confirmed leakage at the arterial or venous–prosthetic anastomosis. Surgical management provided definitive exclusion of the pseudoaneurysm without distal ischemia or postoperative complications.

These observations illustrate how external mechanical pressure can act as a trigger for rupture in structurally fragile, chronically thrombosed vascular segments with residual arterialization.

Even in the absence of functional flow, old vascular access sites remain potential sources of serious vascular complications. Structural fragility resulting from patient comorbidities, repeated surgical and endovascular interventions, uremic toxicity, and accelerated vascular aging may predispose these sites to rupture under mechanical stress.

Healthcare professionals should be aware of this potential complication and consider it in similar clinical circumstances.