JOURNAL OF DIALYSIS, 1(8), 757-761 (1977)
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
ARTERIOVENOUS FISTULA AS A COMPLICATION OF PERCUTANEOUS FEMORAL V E I N C A T H E T E R I Z A T I O N FOR BEMODIALYSIS W.B.
P . F . F a u b e r t , S.Y. C h o u , a n d J.G. Division of Bephrology Department of Medicine The B r o o k d a l e H o s p i t a l M e d i c a l C e n t e r B r o o k l y n , New York 11212 Shapiro,
Porush
A B S T RACT
Sudden o n s e t of c o n g e s t i v e h e a r t f a i l u r e due t o development of a femoral a r t e r l o v e n o u s f i s t u l a i n a h e m o d i a l y s i s p a t i e n t i s r e p o r t e d as a c o m p l i c a t i o n o f r e p e a t e d femoral v e i n c a t h e t e r i z a t i o n f o r access. Closure of t h e f i s t u l a l e d t o disappearance of s i g n s and symptoms o f c o n g e s t i v e h e a r t f a i l u r e . INTRODUCTION
P e r c u t a n e o u s f e m o r a l v e i n c a t h e t e r i z a t i o n is a w e l l known a c c e s s r o u t e f o r h e m o d i a l y s i s s i n c e i t
w a s f i r s t described i n 1961 ( 5 ) .
Complications asso-
c i a t e d w i t h t h i s procedure are i n f r e q u e n t , benign,
rarely life-threatening,
phlebitis,
(1,4,3).
thrombosis
usually
b u t i n c l u d e hematoma,
and r e t r o p e r i t o n e a l b l e e d i n g
Arteriovenous f i s t u l a w i t h r e s u l t a n t conges-
t i v e h e a r t f a i l u r e has h e r e t o f o r e n o t been r e p o r t e d .
757 Copyright @ 1977 hy Marcel Dekker, Inc All Rights Reserved Neither this work nor a n y p u t may be reproduced or transmitted in any form or by any means electronic or mechanical including photocopying, microfilming. and recording. or by any information storage and retrieval system unthout permlssion in writing from the publisher
SHAPIRO ET AL.
758 CASE REPORT
T h e p a t i e n t , a 6 2 y e a r o l d b l a c k f e m a l e w i t h end s t a g e g l o m e r u l o s c l e r o s i s a n d u r e m i a b u t no h i s t o r y o f
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
heart
f a i l u r e , w a s admitted t o the Hemodialysis Unit a t
Thc B r o o k d a l e H o s p i t a l M e d i c a l C e n t e r i n O c t o b e r . 1 9 7 4 f o r t h r i c e weekly t r e a t m e n t s .
A c c e s s was p r o v i d e d by a
b o v i n e g r a f t i n t h e r i g h t arm, n e c e s s i t a t i n g r e v i s i o n s i n December,
1 9 7 4 , May a n d S e p t e m b e r ,
t i n g . During each of
1975, due t o c l o t -
these episodes femoral cannulation
was p e r f o r m e d t w e l v e t i m e s . I n November,
1975, s h e w a s readmitted
episode of g r a f t c l o t t i n g .
for anothec
P h y s i c a l e x a m i n a t i o n w a s un-
remarkable except f o r b i l a t e r a l femoral b r u i t s ,
on t h e l e f t .
louder
Her w e i g h t , h e a r t s i z e , b l o o d p r e s s u r e
(140/80) a n d s e r u m e n z y m e s w e r e u n c h a n g e d f r o m p r e v i o u s admissions.
Two d a y s a f t e r a d m i s s i o n , s h o r t n e s s o f
b r e a t h developed.
P h y s i c a l e x a m i n a t i o n and c h e s t f i l m s
r e v e a l e d p u l m o n a r y e d e m a a n d b l o o d p r e s s u r e was s t i l l 140f80.
A b i l a t e r a l f e m o r a l a r t e r i o g r a m done on t h e
f i f t h h o s p i t a l d a y s h o w e d a n a r t e r i o v e n o u s f i s t u l a on t h e l e f t s i d e ( s e e F i g u r e 1). firmed at surgery.
T h e d i a g n o s i s was c o n -
The f i s t u l a w a s c l o s e d and s i n c e
t h e n t h e p a t i e n t h a s had no f u r t h e r e p i s o d e s o f congestive heart failure.
759
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
ARTERIOVENOUS FISTULA
Figure 1 A r t e r i o g r a m done t h r o u g h t h e r i g h t f e m o r a l a r t e r y showing s i m u l t a n e o u s v i s u a l i z a t i o n o f t h e l e f t f e m o r a l a r t e r y ( s t r a i g h t arrow) and v e i n ( c u r v e d arrow) i n d i cating the presence of a f i s t u l a .
SHAPIRO ET AL.
760 DISCUSSION
A r t e r i o v e n o u s f i s t u l a h a s b e e n r e p o r t e d a s a n uncommon c o m p l i c a t i o n o f a r t e r i a l c a t h e t e r i z a t i o n p e r -
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
formed f o r d i a g n o s t i c p u r p o s e s ( 5 ) .
Percutaneous fem-
o r a l catheterization involves puncture of the femoral v e i n o n l y ; however, d u r i n g t h e procedure t h e a r t e r y may b e a c c i d e n t a l l y e n t e r e d .
In this patient,
one o r
more i n a d v e r t a n t p u n c t u r e s i n t h e a r t e r y m o s t l i k e l y r e s u l t e d i n t h e f o r m a t i o n of t h e f i s t u l a .
The e p i s o d e
of c o n g e s t i v e h e a r t f a i l u r e i n t h i s o t h e r w i s e s t a b l e p a t i e n t was p r o b a b l y r e l a t e d t o t h e p r e s e n c e o f t h e A-V fistula.
A l t h o u g h hemodynamic s t u d i e s w e r e n o t p e r -
formed, t h e f a c t t h a t s h e went i n t o h e a t f a i l u r e i n t h e a b s e n c e o f a r r h y t h m i a , c h a n g e in b l o o d p r e s s u r e , hematocrit,
ECG o r w e i g h t s t r o n g l y s u g g e s t s t h i s e x -
planation.
M o r e o v e r , as o f t h e p r e s e n t
(1 y e a r l a t e r )
s h e h a s n o t had a n o t h e r e p i s o d e o f h e a r t f a i l u r e , f u r ther supporting our contention. -We s u g g e s t t h a t c a r e f u l p h y s i c a l e x a m i n a t i o n w i t h a u s c u l t a t i o n s o f t h e f e m o r a l a r e a b e p e r f o r m e d on a l l p a t i e n t s undergoing repeated percutaneous femoral vein punctures i n order t o detect the unusual complication o f A-V
f i s t u l a formation.
761
ARTERIOVENOUS FISTULA
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
REFERENCES
Menno, A.D.,
1.
Arana, V.A., Hodson, J . M . , J . U r o l . , 106,4 9 2 , 1 9 7 1 .
2.
F a i r b a i r n , J . F . , B e r n a t z , P.E., P e r i p h e r a l Vascular Disease, 4 t h ed., e d i t e d by F a i r b a i r n , J.F., T u e r g e n s , T.L., S p i t e l l , J . A . , J r . , W . B . S a u n d P r s , 1 9 7 4 , pg. 303.
3.
Haut, G . , Amplatz,K.
4.
M e r i n o , G.E., M a u e r , S.M., K j e l l s t r a n d , C.M., C l i n . Neph., C a s a l i , B., B u s e l m e i e r , T . J . , 37, 1975.
5.
S h a l d o n , S., C h i a d a s s l , 857, 1 9 6 1 .
Surgery,
2, 5 9 4 ,
McMahon, J .
1968.
5,
L.,
Higgs, B.,
Lancet,
2,
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
ARTERIOVENOUS FISTULA AS A COMPLICATION OF PERCUTANEOUS FEMORAL V E I N C A T H E T E R I Z A T I O N FOR BEMODIALYSIS W.B.
P . F . F a u b e r t , S.Y. C h o u , a n d J.G. Division of Bephrology Department of Medicine The B r o o k d a l e H o s p i t a l M e d i c a l C e n t e r B r o o k l y n , New York 11212 Shapiro,
Porush
A B S T RACT
Sudden o n s e t of c o n g e s t i v e h e a r t f a i l u r e due t o development of a femoral a r t e r l o v e n o u s f i s t u l a i n a h e m o d i a l y s i s p a t i e n t i s r e p o r t e d as a c o m p l i c a t i o n o f r e p e a t e d femoral v e i n c a t h e t e r i z a t i o n f o r access. Closure of t h e f i s t u l a l e d t o disappearance of s i g n s and symptoms o f c o n g e s t i v e h e a r t f a i l u r e . INTRODUCTION
P e r c u t a n e o u s f e m o r a l v e i n c a t h e t e r i z a t i o n is a w e l l known a c c e s s r o u t e f o r h e m o d i a l y s i s s i n c e i t
w a s f i r s t described i n 1961 ( 5 ) .
Complications asso-
c i a t e d w i t h t h i s procedure are i n f r e q u e n t , benign,
rarely life-threatening,
phlebitis,
(1,4,3).
thrombosis
usually
b u t i n c l u d e hematoma,
and r e t r o p e r i t o n e a l b l e e d i n g
Arteriovenous f i s t u l a w i t h r e s u l t a n t conges-
t i v e h e a r t f a i l u r e has h e r e t o f o r e n o t been r e p o r t e d .
757 Copyright @ 1977 hy Marcel Dekker, Inc All Rights Reserved Neither this work nor a n y p u t may be reproduced or transmitted in any form or by any means electronic or mechanical including photocopying, microfilming. and recording. or by any information storage and retrieval system unthout permlssion in writing from the publisher
SHAPIRO ET AL.
758 CASE REPORT
T h e p a t i e n t , a 6 2 y e a r o l d b l a c k f e m a l e w i t h end s t a g e g l o m e r u l o s c l e r o s i s a n d u r e m i a b u t no h i s t o r y o f
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
heart
f a i l u r e , w a s admitted t o the Hemodialysis Unit a t
Thc B r o o k d a l e H o s p i t a l M e d i c a l C e n t e r i n O c t o b e r . 1 9 7 4 f o r t h r i c e weekly t r e a t m e n t s .
A c c e s s was p r o v i d e d by a
b o v i n e g r a f t i n t h e r i g h t arm, n e c e s s i t a t i n g r e v i s i o n s i n December,
1 9 7 4 , May a n d S e p t e m b e r ,
t i n g . During each of
1975, due t o c l o t -
these episodes femoral cannulation
was p e r f o r m e d t w e l v e t i m e s . I n November,
1975, s h e w a s readmitted
episode of g r a f t c l o t t i n g .
for anothec
P h y s i c a l e x a m i n a t i o n w a s un-
remarkable except f o r b i l a t e r a l femoral b r u i t s ,
on t h e l e f t .
louder
Her w e i g h t , h e a r t s i z e , b l o o d p r e s s u r e
(140/80) a n d s e r u m e n z y m e s w e r e u n c h a n g e d f r o m p r e v i o u s admissions.
Two d a y s a f t e r a d m i s s i o n , s h o r t n e s s o f
b r e a t h developed.
P h y s i c a l e x a m i n a t i o n and c h e s t f i l m s
r e v e a l e d p u l m o n a r y e d e m a a n d b l o o d p r e s s u r e was s t i l l 140f80.
A b i l a t e r a l f e m o r a l a r t e r i o g r a m done on t h e
f i f t h h o s p i t a l d a y s h o w e d a n a r t e r i o v e n o u s f i s t u l a on t h e l e f t s i d e ( s e e F i g u r e 1). firmed at surgery.
T h e d i a g n o s i s was c o n -
The f i s t u l a w a s c l o s e d and s i n c e
t h e n t h e p a t i e n t h a s had no f u r t h e r e p i s o d e s o f congestive heart failure.
759
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
ARTERIOVENOUS FISTULA
Figure 1 A r t e r i o g r a m done t h r o u g h t h e r i g h t f e m o r a l a r t e r y showing s i m u l t a n e o u s v i s u a l i z a t i o n o f t h e l e f t f e m o r a l a r t e r y ( s t r a i g h t arrow) and v e i n ( c u r v e d arrow) i n d i cating the presence of a f i s t u l a .
SHAPIRO ET AL.
760 DISCUSSION
A r t e r i o v e n o u s f i s t u l a h a s b e e n r e p o r t e d a s a n uncommon c o m p l i c a t i o n o f a r t e r i a l c a t h e t e r i z a t i o n p e r -
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
formed f o r d i a g n o s t i c p u r p o s e s ( 5 ) .
Percutaneous fem-
o r a l catheterization involves puncture of the femoral v e i n o n l y ; however, d u r i n g t h e procedure t h e a r t e r y may b e a c c i d e n t a l l y e n t e r e d .
In this patient,
one o r
more i n a d v e r t a n t p u n c t u r e s i n t h e a r t e r y m o s t l i k e l y r e s u l t e d i n t h e f o r m a t i o n of t h e f i s t u l a .
The e p i s o d e
of c o n g e s t i v e h e a r t f a i l u r e i n t h i s o t h e r w i s e s t a b l e p a t i e n t was p r o b a b l y r e l a t e d t o t h e p r e s e n c e o f t h e A-V fistula.
A l t h o u g h hemodynamic s t u d i e s w e r e n o t p e r -
formed, t h e f a c t t h a t s h e went i n t o h e a t f a i l u r e i n t h e a b s e n c e o f a r r h y t h m i a , c h a n g e in b l o o d p r e s s u r e , hematocrit,
ECG o r w e i g h t s t r o n g l y s u g g e s t s t h i s e x -
planation.
M o r e o v e r , as o f t h e p r e s e n t
(1 y e a r l a t e r )
s h e h a s n o t had a n o t h e r e p i s o d e o f h e a r t f a i l u r e , f u r ther supporting our contention. -We s u g g e s t t h a t c a r e f u l p h y s i c a l e x a m i n a t i o n w i t h a u s c u l t a t i o n s o f t h e f e m o r a l a r e a b e p e r f o r m e d on a l l p a t i e n t s undergoing repeated percutaneous femoral vein punctures i n order t o detect the unusual complication o f A-V
f i s t u l a formation.
761
ARTERIOVENOUS FISTULA
Ren Fail Downloaded from informahealthcare.com by McMaster University on 12/09/14 For personal use only.
REFERENCES
Menno, A.D.,
1.
Arana, V.A., Hodson, J . M . , J . U r o l . , 106,4 9 2 , 1 9 7 1 .
2.
F a i r b a i r n , J . F . , B e r n a t z , P.E., P e r i p h e r a l Vascular Disease, 4 t h ed., e d i t e d by F a i r b a i r n , J.F., T u e r g e n s , T.L., S p i t e l l , J . A . , J r . , W . B . S a u n d P r s , 1 9 7 4 , pg. 303.
3.
Haut, G . , Amplatz,K.
4.
M e r i n o , G.E., M a u e r , S.M., K j e l l s t r a n d , C.M., C l i n . Neph., C a s a l i , B., B u s e l m e i e r , T . J . , 37, 1975.
5.
S h a l d o n , S., C h i a d a s s l , 857, 1 9 6 1 .
Surgery,
2, 5 9 4 ,
McMahon, J .
1968.
5,
L.,
Higgs, B.,
Lancet,
2,
