An unusual complication of arteriovenous fistula

A 73-year-old woman undergoing hemodialysis began to develop small skin crusts over a 1.5-cm area in her left forearm, where repeated punctures had been performed to access a native radiocephalic fistula. Over several weeks, these crusts expanded progressively and merged into a single scab. Subsequently, the scab detached from the skin to reveal a large 0.5 by 1.0 cm ulcer that extended onto the surface of a venous stent (Figure 1a and b). There were no apparent signs of local infection, and wound cultures were negative. Antibiotics were administered for a duration of 4 weeks. A computed tomography angiogram of the left arm showed that the vein was patent and contained the stent at the site of exposure (Figure 1c). The forearm portion of the cephalic vein containing the stent was ultimately excised. The structure seen at the base of the ulcer was a Supera stent (Figure 1d) that had been deployed in the cephalic vein 2 years before to address an intractable stenotic lesion (Figure 1e). The complication of an exposed venous stent does not appear to have been reported in the literature. The ulcer likely occurred from repeated punctures, and the adjacent adventitial/medial wall also appeared to be affected by the degenerative process. As such, vascular integrity at this location was essentially secured by a thick intimal layer of hyperplastic and fibrotic tissue (Figure 1e). This complication should serve as a warning against overusing the same confined site to cannulate native hemodialysis accesses. All the authors declared no competing interests. This work was supported by the Canadian Institutes of Health and Research.