Percutaneous antegrade transarterial treatment of iatrogenic radial arteriovenous fistula

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Percutaneous antegrade transarterial treatment of iatrogenic radial arteriovenous fistula Francesco Summariaa, Enrico Romagnolia and Paolo Preziosib Site of access vascular complications is infrequent after transradial interventions. We report the case of a 66-yearold man referred to our hospital because of right forearm swelling, oedema and pain with functional forearm disability, 1 year after a transradial primary percutaneous coronary intervention (PCI). The diagnostic and procedural issues are discussed. This is the first description of a successful and well-tolerated radial arteriovenous fistula (AVF) treatment by means of percutaneous antegrade approach with the use of a short introducer and a biocompatible covered stent.

Introduction Site of access vascular complications are infrequent after transradial interventions.1,2 In particular, arteriovenous fistulas (AVFs) are very rare because of the usual absence of major nerves and large veins near to the radial artery. Generally, about one-third of iatrogenic AVFs close spontaneously within 1 year; for this reason conservative management is often attempted at first. Nevertheless, in some cases a specific treatment is required to prevent serious local disability and circulatory complications.3

Case We report the case of a 66-year-old man referred to our hospital because of right forearm swelling, oedema and pain. One year previously the patient underwent primary transradial angioplasty of the right coronary artery for inferior ST-elevation myocardial infarction. At that time, the artery cannulation was performed with a 16 cm/6 French transradial introducer promptly removed at the end of the procedure without any immediate local complication. One year later the patient returned to our attention due to right forearm swelling and oedema with bruit and thrill at radial artery auscultation and palpation. An echo colour Doppler (ECD) analysis revealed the presence of an AVF at the site of previous radial artery puncture with turbulent high-velocity flow toward the venous district; the collateral circulation was also evaluated confirming the patency of a 3.0 mm diameter ulnar artery with a normal Doppler flow pattern. First we attempted to close the fistula by means of ultrasound-guided compression and prolonged compressive bandage (>12 h), but this was unsuccessful. 1558-2027 ! 2011 Italian Federation of Cardiology

J Cardiovasc Med 2012, 13:50–52 Keywords: arteriovenous fistula, pericardium-covered stent, radial complications, transradial approach a Interventional Cardiology Unit and bDepartment of Radiology, Policlinico Casilino, Rome, Italy

Correspondence to Francesco Summaria, MD, Cath Lab-Policlinico Casilino, Rome, Italy Tel: +39 0623188471; fax: +39 0623188408; e-mail: f.summaria@gmail Received 18 January 2011 Revised 15 February 2011 Accepted 22 February 2011

In consideration of symptom persistence and functional forearm disability we decided to proceed with a percutaneous closure of the fistula. Thus, under ultrasound guidance a short 5 cm 5 French (Ultimum, St. Jude Medical, St. Paul, Minnesota, USA) was positioned in the proximal segment of the right radial artery (antegrade approach). The preliminary angiography confirmed the presence of an AVF made up of the radial artery and two large veins crossing the arterial course and directly connected to the artery by means of a large vascular neck. We positioned a 0.014’ balance middleweight Universal guidewire (Abbott, Illinois, USA) across the palmar arch into the ulnar artery in order to maximize the support. Then a monorail 3.5 ! 18 mm pericardium-covered stent (Aneugraft, ITG Medical, Florida, USA) was implanted into the radial artery at the fistula site. The angiographic control showed the complete exclusion of the anomalous venous connection. The day after, a repeated ECD analysis confirmed the fistula closure. Clinically, the bruit/thrill quickly disappeared and 1 week later we observed a complete resolution of the forearm oedema. The clinical and ECD 6-month follow-up confirmed the patency of the radial artery and the closure of the fistula.

Discussion In our centre more than 96% of the annual total procedures are performed by transradial approach and the annual incidence of vascular complications is about 2.5% including AVF (0.1%), side-branch vessel perforation (0.3%) and acute radial occlusion/thrombosis (2.1%). Moreover, in recent years the improvement in haemostasis care based on accurate systematic vascular DOI:10.2459/JCM.0b013e3283461126

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Iatrogenic radial arteriovenous fistula treatment Summaria et al. 51

Fig. 1

(a) Vascular colour Doppler analysis with high flow turbulence and vein dilation. (b) Vascular colour Doppler analysis confirming the vicinity of radial artery and vein course. (c) Colour Doppler analysis of collateral ulnar flow and diameter integrity. (d) Proximal and distal to the fistula radial artery diameter evaluation.

monitoring by nursing staff4 has significantly reduced the incidence of radial artery occlusion. Although unusual, the superficial course of large veins near to the radial artery, as confirmed by the ECD

analysis and angiography (Figs 1b and 2a), constitutes the more likely physiopathological explanation of AVF formation in this case. The risk of such an unwanted complication might be increased in case of deeper artery course, but data confirming this hypothesis are lacking.

Fig. 2

(a) Diagnostic angiography prior to stent implantation. (b) Antegrade arterial approach with 5F short introducer (5 cm). (c) Pericardium-covered coronary stent implantation. (d) Final angiographic result after stent implantation.

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52 Journal of Cardiovascular Medicine 2012, Vol 13 No 1

Indeed, vascular complication occurrence remains low also when the ulnar artery, usually deeper and smaller than the radial artery, is used.5,6 Although the late spontaneous closure of iatrogenic fistulas is observed in most cases, in our patient it became symptomatic with functional forearm disability 1 year after the procedure. Moreover, the large neck of arteriovenous communication with increased Doppler velocity in the vein outflow excluded the possibility of conservative treatment by means of selective external compression. Previous studies reported successful management of symptomatic radial AVF both with a surgical approach7 and with percutaneous treatment,8 but no data are available about covered stent implantation in this context. The antegrade vascular approach for the catheterization of the upper limb arteries is used with a high procedural success rate, especially in the salvage of nonmaturing native fistulas after transvenous approach failure.9 The choice to implant the pericardium-covered stent in the arterial district instead of the venous one, was based on available device diameter compatible with radial artery calibre and on consideration that the higher arterial flow velocity and pressure would have reduced the risk of stent thrombosis. Finally, the efficacy of the collateral flow from the homolateral ulnar artery was preliminarily assessed in order to avoid any ischaemic complication in case of stent thrombosis or vascular occlusion (Fig. 1c).

In conclusion, AVF is a remote, but possible complication occurring during radial artery catheterization. This is the first description of a successful and well-tolerated radial AVF treatment by means of a percutaneous antegrade approach with the use of a short introducer and a biocompatible covered stent.

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