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A 50-year-old man had a 30-year history of end-stage renal disease associated with idiopathic membranoproliferative glomerulonephritis. His medical history included immune thrombocytopenic purpura, with platelet counts that were persistently less than 15,000 per cubic millimeter. After a second renal transplant failed 8 years ago, the patient began to undergo dialysis through a left brachiocephalic arteriovenous fistula, which became severely aneurysmal over the next 6 years (Panel A), with no evidence of a proximal venous stenosis. There was no evidence of complications — such as infection, embolism, rupture, or high-output congestive heart failure — from this aneurysmal arteriovenous fistula. The patient underwent an elective resection of the arteriovenous fistula, owing to the possibility of life-threatening hemorrhage if the fistula continued to increase in size. The surgical result was satisfactory (Panel B). A subsequent arteriovenous fistula was created in his contralateral arm, progressed in a similar manner over the next 18 months, and also required surgical resection. For the past 12 months, the patient has undergone hemodialysis through a third arteriovenous fistula that is currently nonaneurysmal.
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