A patient with end-stage renal disease treated with peritoneal dialysis had two old, thrombosed hemodialysis access grafts in her upper limb. She presented with the puzzling problem of a slowly recurring hematoma over the venous anastomo sis of the upper arm graft. When the hematoma was explored surgically, its source was not immediately apparent; however, when the arterial anastomosis of the upper arm graft was subsequently explored, a small anastomotic pseudoaneurysm was encountered. Blood from the pseudoaneurysm had been dissecting between the graft and its fibrous tunnel and slowly accumulating at the venous anastomosis. Pseudoaneurysms occur in less than 5% of dialysis access grafts. They almost invariably present as a pulsatile hematoma over the arterial anastomosis or over a needle hole in a patent graft. The case described herein is interesting because of its unique presentation.
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