We present a case of acute graft thrombosis with a concomitant pseudoaneurysm and iatrogenic fistulous tract that required surgical intervention to restore function. A 58-year-old male with end stage renal disease due to diabetic nephropathy had been undergoing hemodialysis since 2021 via a left brachio-basilic forearm loop AVG. On January 31, 2025, he was referred to our facility due to the absence of thrill and suspected acute thrombosis of the AVG. On visual inspection, multiple pseudoaneurysms were observed in the cannulation zone of the AVG (Figure 1A). Physical examination revealed the absence of thrill, but a bruit was detected in the proximal arterial limb. Ultrasound examination showed a brachial artery blood flow rate (BFR) of 1200 mL/min with thrombus formation extending from the proximal third of the arterial limb to the basilic vein in the axillary region. Additionally, a pseudoaneurysm was noted in the arterial limb puncture zone, with an associated iatrogenic fistulous connection between the graft and an adjacent vein (Figure 1B-D). The patient underwent thrombectomy and percutaneous transluminal angiography (PTA), achieving complete thrombus removal as confirmed by post-procedural fistulography. However, persistent flow diversion into the iatrogenic fistulous tract was observed, reducing effective graft function.(Figure 2A) To maintain patency, we opted to ligate the collateral vein connected to the pseudoaneurysm in the arterial limb cannulation zone.(Figure 2B) Following the procedure, successful ligation of the fistulous tract was confirmed, and the collateral veins disappeared. The graft remained patent, and the patient resumed hemodialysis without further complications. Pseudoaneurysms and iatrogenic fistulous connections can arise from repeated cannulations in AVGs, compromising access durability. In cases where PTA and thrombectomy do not fully restore flow due to collateral pathways, surgical ligation of aberrant vessels may be necessary to maintain access functionality.