Surgical Management of a Chronic High-flow Arteriovenous Fistula with Pseudoaneurysm and Nerve Entrapment after Failed Percutaneous Ligation: A Case Report

Minimally invasive flow-reduction techniques such as Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) and No-Incision Limited Ligation Indwelling Needle-assisted Revision (NILLINR) have gained popularity for Arteriovenous Fistula (AVF) management. Still, their applicability in complex, long-standing, or structurally abnormal fistulas remains uncertain. We present a rare and challenging case of a young renal transplant recipient who developed multiple complications after failed percutaneous AVF ligation. A 30-year-old man, two years post-renal transplant and off dialysis, presented with palpitations, visible fistula prominence, and sensory loss in the dorsoradial hand region, 10 days after undergoing ultrasound-guided AVF ligation at another centre. Clinical examination revealed a constriction band at the ligation site, pseudoaneurysm, venous blowouts, and thrill. Intraoperatively, a large pseudoaneurysm, severely dilated and calcified veins, and a 6-7 cm remodelled radial artery segment were identified. Importantly, the superficial branch of the radial nerve was found entrapped within the ligature, explaining the sensory deficit. Surgical management included excision of the pseudoaneurysm and diseased veins, release and preservation of the trapped nerve, and secure ligation of blowouts. Given excellent collateral perfusion from the ulnar artery and palmar arch, arterial reconstruction was avoided. Postoperatively, the patient’s palpitations subsided, cosmesis improved, and gradual neurological recovery was noted. This case highlights several important learning points: (i) percutaneous ligation may fail in aneurysmal or calcified vessels; (ii) high-output AVFs can cause systemic manifestations such as palpitations; and (iii) nerve entrapment is a rare but serious complication of percutaneous techniques. Surgical takedown with careful intraoperative assessment offers definitive management in such complex anatomical scenarios.