부산대학교 도서관

A 48-year-old man was started on hemodialysis with an arteriovenous fistula (AVF) in the left forearm seven years ago. An AVF aneurysm appeared three years previously, and because its long diameter increased to 55 mm, he was referred to our hospital. Aneurysmectomy and aneurysmoplasty require a large incision, and graft replacement is likely to cause anastomotic stenosis. For these reasons, we chose graft insertion into the aneurysm by applying the ʻgraft inclusion techniqueʼ. About 2-cm skin incisions were made up- and downstream of the aneurysm and the in- and outflow vessels were secured. We confirmed that the aneurysm collapsed by clamping these vessels. A semi-circumferential incision was made on the anterior wall of the inflow vessel. After coating with sterilized jelly, a tunneler with an external cylinder was inserted into the inflow vessel and was passed through the aneurysm under ultrasound guidance and reached the outflow vessel. A semicircumferential incision was made in the anterior wall of the outflow vessel, and the tunneler was guided out of the vessel through the incision. After leaving the outer cylinder of the tunneler, a 5-mm ePTFE graft was inserted therein. By subsequently removing the outer cylinder, the graft was left in the vessel across the aneurysm. Both ends of the graft were trimmed and sutured to fix the stumps to the vessel wall to close the incisions. After releasing the clamps, it was confirmed that the aneurysm was not re-bulging and the thrill was good, and the operation was completed. There was no anastomotic stenosis or recurrence of the aneurysm for 2.5 years after the operation. This is a simple procedure that involves only two small incisions and does not require aneurysm resection or end-to-end anastomosis. Therefore, it can be an option in radical surgery for an AVF aneurysm.