Hemodialysis International 2015; 19:E29–E32

Complications

An unusual cause of postdialysis dyspnea: Percutaneous endovascular management Yashwant PATIDAR,1 Taruna YADAV,1 S RAJESH,1 Suman LATA,2 Sachin KUMAR,3 Amar MUKUND1 Departments of 1Radiodiagnosis, 2Nephrology and 3Pulmonary Medicine, Institute of Liver and Biliary Sciences, New Delhi, India

Abstract Vascular access through femoral vein is commonly used for hemodialysis treatment in patients with end-stage renal disease. Consequently, iatrogenic complications, such as femoral arteriovenous fistula, are increasingly being reported in these patients. Percutaneous endovascular management of such iatrogenic arteriovenous fistulas with stent graft placement is a minimally invasive technique with decreased morbidity and hospital stay compared with surgical repair. Here, we report a case with postcatheterization arteriovenous fistula between superficial femoral artery and femoral vein which was successfully managed with a placement of a self-expanding stent graft. Key words: Arteriovenous fistula, post-dialysis, stent graft

INTRODUCTION An arteriovenous fistula (AVF) is defined as an abnormal communication between an artery and a vein. Femoral AVFs almost always develop secondary to penetrating injuries and percutaneous vascular interventions.1 The clinical course of AVFs after catheterization may vary significantly ranging from spontaneous closure over a period of time to complications such as limb edema, limb ischemia, high output cardiac failure, and aneurysmal degeneration of the artery.1,2 Different modalities of treatment are available for this complication including surgical repair and percutaneous Correspondence to: Y. Patidar, MD, Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi 110070, India. E-mail: [email protected] Study performed at Department of Radiodiagnosis, Department of Nephrology and Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India. Ph: +91-11-46300000. Fax: +91-1126123504.

endovascular management. However, endovascular management of such iatrogenic complications has become the preferred method of treatment in recent years because of various advantages over surgery.2

CASE REPORT A 37-year-old man with ethanol-related chronic liver disease presented to our hospital with decreased urine output, abdominal distension, and generalized swelling for 2 weeks. Blood investigations showed blood urea levels of 205 mg/dL, serum creatinine levels 9.13 mg/dL, deranged liver function tests, prothrombin time of 22.6 seconds and international normalized ratio (INR) of 1.97. A clinical diagnosis of chronic liver parenchymal disease with hepatorenal syndrome type 1 was made. Femoral vein catheterization was performed and a double lumen dialysis catheter was placed to perform hemodialysis. The patient underwent an uneventful hemodialysis; however, the patient had continued oozing from the puncture site after removal of the femoral catheter which was managed with local compression for 20 minutes. After 12 hours, the

© 2015 International Society for Hemodialysis DOI:10.1111/hdi.12287

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patient had mild swelling of the right lower limb and complained of dyspnea. Chest X-ray showed cardiomegaly with increased pulmonary vascularity (Figure 1). So, a suspicion of developing high-output cardiac failure was made. Doppler ultrasound examination of the groin was performed at the site of catheterization which revealed highresistance arterialized flow in the femoral vein giving rise to a suspicion of AVF. So, digital subtraction angiography (DSA) was performed to locate the exact site of the arteriovenous communication and to plan further the line of management. Right femoral vein DSA was performed using left femoral approach which revealed an AVF communicating to the proximal portion of the right superficial femoral artery (SFA) and femoral vein (Figure 2a,c). After selective catheterization and calibration, a self-expanding stent graft (fluency plus vascular stent, 8 × 40 mm) was placed across the site of the AVF in SFA to cut-off the iatrogenic arteriovenous communication. Chest angiogram (Figure 2d) confirmed the optimal position and patency of the covered stent and the absence of the filling of the femoral vein consistent with complete closure of the AVF. The patient improved symptomatically with decrease

Figure 1 Chest Anteroposterior (AP) view radiograph showing cardiomegaly perihilar haziness with prominence of bilateral upper lobe vessels.

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in right limb edema, respiratory distress, and was discharged after 3 days.

DISCUSSION Arteriovenous fistulas following percutaneous catheterization are usually small, asymptomatic, and may close spontaneously over several months. The incidence of postcatheterization AVFs ranges from 0.006 to 0.86%.3 Clinical history and physical examination are helpful in making a diagnosis of AVF. On physical examination, a thrill on palpation and bruit on auscultation are suggestive. The patient may also have limb ischemia because of steal phenomena and limb edema, and dyspnea because of increased venous return owing to decreased peripheral vascular resistance.4 Different imaging modalities such as the Doppler ultrasound, computerised tomography (CT) angiography, and magnetic resonance (MR) angiography are helpful for diagnosis of AVF. However, DSA is required in many cases for accurate site localization and tailoring of the surgical or endovascular treatment.5 Different modalities of treatment for peripheral limb AVFs include surgical repair and percutaneous endovascular interventional management. Surgical options are partial resection, ligation, and primary repair. Disadvantages of surgical treatment include its more invasive nature, surgical scar, increased hospital stay, and patient comorbidity. Extensive dissection in surgical repair can cause wound complications such as hematomas and infection. In addition, the fistula is sometimes difficult to find.6–8 Over the past few years, endovascular techniques have emerged as an effective alternative to surgical treatment. Stent graft placement for treatment of AVFs is a preferred method as it is technically easy and has been reported to have a high technical success rate and a low complication rate. It is particularly advantageous to patients suffering from cardiovascular disease as the amount of blood loss that can increase during surgical repair because of venous hypertension is decreased when covered stents are used.7 Percutaneous endovascular treatment also has inherent technical complications such as stent thrombosis, stent migration, endoleak, and obstruction of the side branches. An AVF close to the bifurcation of the common femoral artery is a relative contra-indication for endovascular treatment because of the risk of closing off the superficial or deep femoral artery.7 In our case also, the AVF was located in the proximal SFA which was treated with stent graft placement without compromising the SFA, deep femoral artery, or any other branches so, it is feasible to

Hemodialysis International 2015; 19:E29–E32

An unusual cause of postdialysis dyspnea: Endovascular management

Figure 2 Digital substraction angiography images (a) reveal simultaneous femoral venous filling (curved arrow) on contrast injection in distal common femoral artery. (b) Selective contrast injection in deep femoral artery (thick arrow) shows the absence of filling of femoral vein. (c) However, selective proximal superficial femoral artery (arrowhead) injection shows simultaneous filling of femoral vein confirming the site of arteriovenous fistula (AVF). (d) Angiography after stent graft placement (arrows showing radiopaque markers of stent graft) shows complete closure of AVF with maintained patency of all the branches.

treat such AVFs with optimal placement of stent with good technical expertise.

DISCLOSURES None. Manuscript received December 2014.

REFERENCES 1 Straton CS, Tisnado J. Spontaneous arteriovenous fistulae of the lower extremities: Angiographic demonstration in

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five patients with peripheral vascular disease. Cardiovasc Intervent Radiol. 2000; 23:318–321. 2 Thalhammer C, Kirchherr AS, Uhlich F, Waigand J, Gross CM. Postcatheterization pseudoaneurysms and arteriovenous fistulas: Repair with percutaneous implantation of endovascular covered stents. Radiology. 2000; 214:127– 131. 3 Kelm M, Perings SM, Jax T, et al. Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: Implications for risk stratification and treatment. J Am Coll Cardiol. 2002; 40:291–297. 4 Cil BE, Akmangit I, Peynircioglu B, Karçaaltincaba M, Cekirge S. Iatrogenic femoral arteriovenous fistula: Endovascular treatment with covered stent implantation and 4-year follow-up. Diagn Interv Radiol. 2006; 12:50–52.

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5 Parodi JC, Schonholz C, Ferreira LM, Bergan J. Endovascular stent-graft treatment of traumatic arterial lesions. Ann Vasc Surg. 1999; 13:121–129. 6 Uflacker R, Elliott BM. Percutaneous endoluminal stentgraft repair of an old traumatic femoral arteriovenous fistula. Cardiovasc Intervent Radiol. 1996; 19:120–122. 7 Marin ML, Veith FJ, Panetta TF, et al. Percutaneous transfemoral insertion of a stented graft to repair a traumatic

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femoral arteriovenous fistula. J Vasc Surg. 1993; 18:299– 302. 8 Ruebben A, Tettoni S, Muratore P, Rossato D, Savio D, Rabbia C. Arteriovenous fistulas induced by femoral arterial catheterization: Percutaneous treatment. Radiology. 1998; 209:729–734.

Hemodialysis International 2015; 19:E29–E32

An unusual cause of postdialysis dyspnea: Percutaneous endovascular management.

Vascular access through femoral vein is commonly used for hemodialysis treatment in patients with end-stage renal disease. Consequently, iatrogenic co...
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