Nephrologist-performed point-of-care ultrasound enables early recognition of PTFE hemodialysis graft pseudoaneurysm: a case report

Pseudoaneurysm is a recognized complication of polytetrafluoroethylene (PTFE) hemodialysis grafts and may be associated with rupture, infection, thrombosis, and vascular access loss. While Doppler ultrasound findings are well established, the incorporation of nephrologist-performed point-of-care ultrasound (POCUS) within dialysis units may facilitate timely bedside recognition and expedited referral in high-risk patients. We report the case of a 53-year-old woman with end-stage kidney disease secondary to lupus nephritis, receiving maintenance hemodialysis since 2013, who presented with pain, swelling, fever, local warmth, and a rapidly enlarging pulsatile mass over a brachioaxillary PTFE graft. Physical examination revealed hyperemia, thinning of the overlying skin, and cutaneous shininess suggestive of impending rupture. Bedside POCUS performed by the attending nephrologist inside the dialysis unit demonstrated a 1.94 × 0.6 cm pseudoaneurysm communicating with the graft lumen through a narrow neck measuring approximately 0.24 × 0.35 cm, associated with turbulent bidirectional flow and the characteristic “yin–yang” sign on color Doppler imaging. The examination enabled immediate bedside confirmation and expedited referral to a tertiary vascular center. Computed tomography angiography (CTA), requested for surgical planning and evaluation of lesion extent and suspected contained rupture, confirmed active contrast extravasation. Due to vascular access exhaustion, an initial conservative strategy with broad-spectrum antibiotics was attempted. Blood cultures subsequently grew Enterococcus faecium, and transthoracic echocardiography revealed tricuspid valve infective endocarditis with severe tricuspid regurgitation. Despite partial infectious improvement with directed antimicrobial therapy, graft excision was ultimately required and was complicated by intraoperative hemorrhagic shock. The patient required prolonged intensive care admission, central venous angioplasties, and tunneled femoral catheter placement for dialysis continuation. This case illustrates the feasibility of nephrologist-performed POCUS in the dialysis unit as a rapid problem-focused tool for early recognition of vascular access complications and expedited referral for definitive management. Limitations include the single-case design, operator dependency, absence of spectral Doppler interrogation, and lack of long-term vascular access outcomes.