Double Trouble: A Rare Case of Bilateral Arteriovenous Fistula Pseudoaneurysms in End-stage Renal Disease

Abstract Arteriovenous fistulas (AVFs) are the preferred vascular access for hemodialysis but are prone to complications such as stenosis, thrombosis, aneurysm, and pseudoaneurysm formation. Pseudoaneurysms, although rare, can lead to life-threatening rupture. We report a 19-year-old female with end-stage renal disease on maintenance hemodialysis who developed bilateral AVF pseudoaneurysms, with rupture on the right and impending rupture on the left. The left hand also showed raising concerns for venous hypertension with possible ischemic features, probably due to the steal phenomenon. Emergency pseudoaneurysm excision and AVF ligation were performed on the right, whereas elective excision with radial artery reconstruction was done on the left. The patient had an uneventful recovery with improved hand perfusion, and a new AVF was later created. This case underscores the importance of early recognition and tailored surgical management in rare cases of bilateral AVF pseudoaneurysms, especially in the presence of ischemic complications.