Case Report
Percutaneous Closure of Iatrogenic Femoral
Arteriovenous Fistula Using Endovascular Covered
Stent
NO Bansal, V Bhatia, V Viswanathan, S Sreekanth
Abstract
Local complications after femoral arterial catheterization, such as hematomas, pseudoaneurysms,
arteriovenous fistulas (AV fistulas), and arterial occlusions, are becoming more common, with the growing
number of complex invasive procedures being undertaken, especially in older and sicker patients. Newer
percutaneous techniques are being developed to treat these. Covered stents are an effective, safe, and less
invasive way to deal with pseudoaneurysms and AV fistulas. This case report highlights the application of
this technique to treat an iatrogenic femoral AV fistula in a 69 years male ©
INTRODUCTION
C
overed stent grafts are being increasingly used to
treat aneurysms, arteriovenous fistulas and
coronary artery perforations. They provide an easy,
reliable and highly efficacious percutaneous technique
of dealing with these complications, for which
previously only surgical options were available.
Nevertheless using meticulous technique a vast majority
of these complications can be avoided.
CASE REPORT
A 69 years male known hypertensive was admitted
in 1996 for chest pain. His coronary angiogram (CAG)
then revealed left anterior descending artery (LAD)
proximal 75% stenosis, 1 st diagonal 90% and left
circumflex (LCX) 90% stenosis. He declined
revascularisation and was discharged on optimal
medical treatment. Subsequently he suffered Inferior wall
myocardial infarction in 1999 after which he underwent
PTCA and stenting to LCX. Six weeks post procedure on
regular follow up the patient’s diastolic blood pressure
was detected to be 50 mm Hg along with a pulsatile
swelling in right groin (the side from where intervention
was done). There was an audible bruit over the swelling,
which was confirmed to be an arteriovenous fistula (on
color Doppler study) between the common femoral artery
and common femoral vein. He was advised surgical
closure of the same but declined. In 2004 he was
readmitted with fresh coronary symptoms, underwent
Department of Cardiology, Grant Medical College and Sir JJ
Group of Hospitals, Mumbai.
Received : 4.9.2004; Accepted : 28.12.2004
150
CAG followed by PTCA and stenting to right coronary
artery and LCX via the left groin approach. Peripheral
angiogram revealed a large fistulous communication
between right common femoral artery and vein (Fig. 1) .
Patient was given the option of percutaneous closure of
the AV fistula for which he agreed. A left sided approach
was not technically possible due to severe acute bend at
the aortic bifurcation, across which negotiating the long
covered stent was not feasible. The right femoral artery
was cannulated using bony landmarks below the site of
the fistulous communication by a puncture which was
made in the thigh. A 0.035 inches J tipped guide-wire
Fig. 1 : Fistula seen between right common femoral artery and
femoral vein
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Fig. 2 : 48 mm Jo stent graft placed across fistulous AV
communication, second communication seen above the first
(not evident previously)
was placed in the right common iliac artery and
descending aorta. This was followed by deployment of
a 48 mm, 6-9 mm JoMed covered stent graft mounted on
a 6x40 mm balloon. Check angiogram revealed
obliteration of the fistulous communication but another
tract became evident feeding the right femoral vein (Fig.
2). In lieu of this a second 38 mm, 6-9 mm, covered stent
graft was deployed mounted over a 6x40 mm balloon
(Fig. 3). Check angiogram revealed complete obliteration
of the arteriovenous communication and femoral vein
did not fill from the femoral artery (Fig. 4).
Fig. 3 : Second 38 mm Jo stent graft placed above the first
DISCUSSION
During vascular access, the Seldinger needle
puncturing the femoral artery and overlying femoral
vein, creating an AV fistula after sheath withdrawal is a
well known complication described in literature. The
risk of developing AV fistula increases if multiple
attempts are made to obtain femoral access, puncture is
high (involving the common femoral artery and lateral
femoral circumflex vein), or low (after common femoral
has divided into the superficial femoral artery and
profunda femoris artery, the profunda overlies the
femoral vein) and impaired clotting.1 Hence meticulous
care is needed while obtaining vascular access often
taking the help of bony landmarks under fluoroscopy if
necessary.
The incidence of AV fistula formation following
diagnostic and therapeutic cardiac catheterization is 0.11.5%.2
Clinically the patients may have a local bruit, distal
arterial insufficiency (steal phenomenon), a swollen and
tender extremity due to venous dilatation.
Diagnosis can be confirmed at color Doppler
examination.
Management–Small AV fistulas may close
© JAPI • VOL. 53 • FEBRUARY 2005
Fig. 4 : Complete obliteration of the fistulous tract
spontaneously.3 Ultrasound guided compression may
be attempted for small fistulae but experience is limited.4
For large or symptomatic AV fistulae surgical or
percutaneous closure is recommended to prevent
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151
accelerated atherosclerosis, high output failure and
progressive swelling and tenderness. Surgical repair
involves division or excision of the fistula or synthetic
grafting of the vessel in unusual cases. Endovascular
stent grafts are now being increasingly used to close
such AV fistulae. The stent graft is made up of two 316L
high grade surgical steel stents between which
Polytetrafloroethylene (PTFE) is sandwiched. PTFE is
expandable, nonporous, has no additional
thrombogenicity5 and is about 150 microns in thickness.
Autologus venous6 and arterial covered stent grafts
(using radial artery) have also been used in coronary
arteries. Endothelial and neointimal cells gradually
cover the device until an intact cellular coating has been
formed after a few weeks. Burger et al did not report any
evidence of intimal hyperplasia, occlusion or stent graft
migration at seven months follow up while Thalhammer
et al reported stent thrombosis rates of 17% in a larger
series of 26 patients on one year followup. Apart from
this application stent grafts can also be used to seal off
coronary artery perforations and treat aneurysms.
REFERENCES
1.
Rosenfield K,Goldstein JA, Safian RD. Medical and peripheral
vascular complications. In: Safian RD, Freed MS, eds. The
Manual of Interventional cardiology. 3 rd edition. Michigan:
Physicians Press 2001:483.
2.
Muller DWM, Shamir KJ, Ellis SG, et al. Peripheral vascular
complications after conventional and complex percutaneous
coronary interventional procedures. Am J Cardiol 1992;69:6388.
3.
Kent KC, Moscucci M, Mansour KA, et al. Retroperitoneal
hematoma after cardiac catheterization;prevalence,risk
factors and optimal management. J Vasc Surg 1994 ;20:90510:discussion 910-13.
4.
Schaub F, Theiss W, Heinz M, et al. New aspects in the
ultrasound guided compression repair of post-catheterisation
femoral arterial injuries. Circulation 1994;90:1861-5.
5.
Morice M-C, Kumar R, Lefevre T, et al. The French registry of
coronary stent grafts; acute and long term results. JACC
(suppl)1999;33:36A
6.
Saijo Y, Izutsu K, Sonobe T, et al. Sucessful closure of
coronary-bronchial artery fistula with vein –coated stent .
Cathet Cardiovasc diagn 1999;40:214-7.
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