Brachial artery pseudoaneurysm arising from the stump of a ligated arteriovenous fistula

An 85-year-old man presented to A&E department with a bleeding, pulsatile mass within the left antecubital fossa. He reported a 3-month history of an increasing, painless swelling. He had a history of end-stage renal failure secondary to antiglomerular basement membrane disease. 14 years prior, he had a left brachiocephalic fistula created, which was ligated shortly after its creation due to Steal syndrome. Examination revealed a 10×15×10 cm pulsatile, non-tender mass with overlying ulceration in the left antecubital fossa. Arterial duplex demonstrated a pseudoaneurysm arising from the left distal brachial artery with a 9 mm neck. The patient underwent surgical exploration and repair. At surgery, a large brachial artery pseudoaneurysm at the site of the previous fistula ligation was found. The overlying ulcerated skin and pseudoaneurysm were excised en mass, and the arterial defect repaired by transection and end-to-end anastomosis. This is the first reported case of a brachial artery pseudoaneurysm occurring following arteriovenous fistula ligation.