Repair of femoral postcatheterization pseudoaneurysm and arteriovenous fistula with percutaneous implantation of endovascular stent

Uwe Brümmer1, Matteo Salcuni2, Filippo Salvati3 and Mario Bonomini1

1 Institute of Nephrology 2 Institute of Radiology, G. D'Annunzio University, Chieti 3 Division of Medicine, Ospedale SS, Immacolata-Guardiagrele, Italy

Sir,

The formation of combined arteriovenous fistula (AVF) and pseudoaneurysm is an uncommon event after catheterization of the femoral vein for haemodialysis. The evolution of pseudoaneurysm is continued expansion and eventually rupture, and large injuries to peripheral arteries may result in significant late sequelae if left untreated [1,2]. Therefore, these complications should be repaired. We observed a case of femoral AVF after venous catheterization associated with a large pseudoaneurysm, which could be successfully repaired with a percutaneously placed stent graft.

Case.

A 73-year-old male patient on intermittent haemodialysis was admitted to our hospital with a prominent skin lesion under the right groin. Two weeks before admission, because of the closure of his native AVF located on the upper left arm, a single lumen catheter was placed in the right femoral vein. After 2 days, because of bleeding, the haemodialysis device was removed and replaced by a subclavian catheter.

On physical examination at admission the skin lesion appeared to be a pulsatile mass with a palpable thrill and an audible to-and-fro murmur. Duplex femoral ultrasonography documented the presence of a pseudoaneurysm, and a femoral arteriogram demonstrated a fistula between the right superficial femoral artery and the right common femoral vein (Figure 1AGo).



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Fig. 1. (A) Femoral arteriogram showing arteriovenous fistula associated with large pseudoaneurysm between right superficial femoral artery and right common femoral vein. (B) Angiogram after placement of the stent graft showing no aneurysm or fistula.

 
A peripheral balloon-expandible stent graft (Jostent, Jomed GmbH, Rangendingen, Germany) was mounted on a 0.7x4 cm angioplasty balloon catheter and preloaded into a 7F introducer system (Super Arrow Flex, Arrow International Inc., Reading, PA, USA). This device was inserted percutaneously into the common left femoral artery and was advanced under fluoroscopic guidance to the origin of the AVF. After achieving stent graft expansion (7 mm) by balloon development, an angiographic control documented complete closure of the fistula and the pseudoaneurysm (Figure 1BGo). The patient had an uncomplicated recovery and was discharged 2 days later. Repeated duplex sonograms showed persistent obliteration of the fistula and normal arterial and venous flow during 6 months of follow-up.

Comment.

Repair of traumatic AVFs and pseudoaneurysms include surgical management, duplex guided compression, percutaneous coil embolization, and percutaneous implantation of endovascular covered stents. Small femoral pseudoaneurysms (less than 2 cm) usually clot spontaneously requiring no treatment [4]. Small infrainguinal AVFs may resolve spontaneously [5] or close after duplex ultrasonographic controlled external compression [6]. In the past, larger pseudoaneurysms and AVFs or combined lesions were treated surgically to prevent complications like enlargement of the pseudoaneurysm with the resulting risk of haemorrhage, arterial thrombosis, compression of adjacent neurovascular structures, cutaneous ulceration, venous hypertension, and high output congestive heart failure. Haemodialysis patients with severe medical comorbidities may have important operative morbidity and mortality rates [3]. Therefore, surgery should be preferably reserved for emergency cases, whereas patients with stable AVFs and pseudoaneurysms may be managed with less invasive methods. The endoluminal vascular repair with stent graft offers the advantage of a minimally invasive approach, no surgical incision, a reduced risk of infection and shortened hospitalization and may therefore represent an effective and safe therapeutic approach in patients with end-stage renal disease.

References

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  2. Escobar GA, Escobar SG, Marquez L et al. Vascular trauma: late sequelae and treatment. J Cardiovasc Surg1980; 21: 35–40[ISI][Medline]
  3. Messina LM, Brothers TE, Wakefield TW et al. Clinical characteristics and surgical management of vascular complications in patients undergoing cardiac catheterization: interventional versus diagnostic procedures. J Vasc Surg1991; 13: 593–600[ISI][Medline]
  4. Kronzon I. Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysms: a review. J Am Soc. Echocardiogr1997; 10: 236–245[ISI][Medline]
  5. Billings KJ, Nasca RJ, Griffin HA. Traumatic arteriovenous fistula with spontaneous closure. J Trauma1973; 13: 741–743[ISI][Medline]
  6. Feld R, Patton GM, Carabasi A. Treatment of iatrogenic femoral artery injuries with ultrasound guided compression. J Vasc Surg1992; 16: 832–840[ISI][Medline]




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