History and examination
A 54-year-old female end-stage kidney disease patient on maintenance hemodialysis three times per week for the past 2 years after she was diagnosed to have pulmonary-renal syndrome for which she has been getting prednisolone 5mg orally daily since 2 years back. The pulmonary symptoms including cough with hemoptysis have improved with the prednisolone.  She has an arteriovenous fistula (AVF) on the left arm used for hemodialysis currently and the AVF on the right arm is not functional.  She also had toxic nodular goiter and hypertension for the past 10 years. Currently, she is on amlodipine 10mg orally per day, propylthiouracil (PTU) 100mg twice per day, erythropoietin alpha 4000 IU SC weekly, and prednisolone 5mg orally daily.
Her current presentation is progressively increasing pulsatile swelling over the right medial side of the mid-thigh which progressed over 7 months with numbness on the same side; it concerns her as its size started to increase over the past 3 months but it has not bothered her for the first 4months. She never had hemodialysis catheter insertion on the right femoral vein. There was no trauma, surgery, or venipuncture on the leg. There is no history of similar problems on another site. There is no history of smoking, alcohol drinking, or other substance use. There was no other chronic illness other than the mentioned ones. She had been treated for severe hospital-acquired pneumonia (HAP) for 1 week after she had been admitted for intervention for which parenteral antibiotics were given for 7 days.
On physical examination: she is well-looking and well-nourished woman with blood pressure, heart rate, respiratory rate, and oxygen saturation of  130/80, 80, 24, and 96% respectively. S1/2 was well heard and there was no murmur; there was a matured arteriovenous fistula (AVF) with palpable thrill on the left cubital area and some on the right arm. There is an 8 - 9cm length pulsatile mass on the medial aspect of the thigh with palpable thrill.