Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 105-107

Iatrogenic arteriovenous fistula involving the radial artery and cephalic vein of the right upper limb: Manifesting as concomitant aneurysms of the same


Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir Jamshedjee Jeejebhoy Group of Hospitals, Mumbai, Maharashtra, India

Date of Submission01-May-2020
Date of Decision05-May-2020
Date of Acceptance19-May-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
Saptarshi Paul
Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir Jamshedjee Jeejebhoy Group of Hospitals, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_46_20

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  Abstract 


Arteriovenous fistula (AVF) is defined as an anomalous communication between an artery and a vein. Iatrogenic AVFs are a rare clinical finding compared to the congenital type. They are most commonly secondary to penetrating and blunt trauma, iatrogenic complications of invasive procedures, and operations. Although still rare, iatrogenic AVFs are more commonly reported now due to the increased use of percutaneous diagnostic and interventional endovascular procedures. Here, we present the case report of a 22-year-old female, who had undergone intravenous (IV) cannulation in the right forearm volar aspect, for IV antibiotics, as a treatment of typhoid fever. Five years after the procedure, she developed an aneurysmal swelling in the volar aspect of the right forearm, which on computed tomography revealed two aneurysms lying next to each other with a communication akin to a fistula. The dual aneurysms were completely resected.

Keywords: Concomitant arteriovenous aneurysm, iatrogenic arteriovenous fistula, intravenous cannulation


How to cite this article:
Paul S. Iatrogenic arteriovenous fistula involving the radial artery and cephalic vein of the right upper limb: Manifesting as concomitant aneurysms of the same. Indian J Vasc Endovasc Surg 2021;8:105-7

How to cite this URL:
Paul S. Iatrogenic arteriovenous fistula involving the radial artery and cephalic vein of the right upper limb: Manifesting as concomitant aneurysms of the same. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Mar 1];8:105-7. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/105/309713




  Introduction Top


Arteriovenous fistula (AVF) is defined as an anomalous communication between an artery and a vein.[1],[2] An arterial pseudoaneurysm, or false aneurysm, is caused by the damage to the arterial wall, resulting in locally contained hematoma with turbulent blood flow and a neck that typically does not close spontaneously once past a certain size. Acquired AVFs are a rare clinical finding compared to the congenital type. They are most commonly secondary to penetrating and blunt trauma, iatrogenic complications of invasive procedures and operations, infection, aneurysm, and blood vessel inflammation.[3] Here, we are highlighting a case of a 22-year-old lady who had reported with a traumatic AVF with concomitant aneurysms in both.


  Case Report Top


A 22-year-old girl was referred to the Cardiovascular and Thoracic Surgery Department of our institute, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, with complaints of a gradual painless progressive pulsatile compressible swelling on the ventral aspect of the right wrist. The onset was insidious with a gradual increase in size, following an intravenous (IV) cannulation for administering antibiotics for typhoid fever approximately 5 years back. The IV cannula was inserted in the right hand at the wrist level on the volar aspect. However, no apparent damage to the radial artery, namely, an hematoma was noticed at that time. The patient noticed a swelling 2 weeks after getting discharged from the hospital that progressively increased in size. There was no history of pain. Swelling was approximately 35 mm × 35 mm × 27 mm at the time of presentation. Sensory and motor function was intact. The ulnar artery was easily palpated, with negative Allen's test. Computed tomography angiogram showed a nonopacifying lesion in the distal forearm measuring approximately 31 mm × 27 mm × 35 mm [Figure 1]. An opacifying channel which is in continuity with the distal radial artery is seen traveling through the lesion measuring 3.6 mm in caliber. A shunt channel measuring 4.3 mm in caliber arose from the intralesional part of the radial artery and supplying venous channels.
Figure 1: Volume rendering technique image showing arterial and venous aneurysms as well as the fistulous connection

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Operative procedure

The patient underwent resection of the radial artery aneurysm along with the concomitant cephalic venous aneurysm, with takedown of the AVF. The surgery was performed under right brachial plexus block.

Intra-operative findings

Two small longitudinal incisions were made, immediately proximal and distal to the aneurysmal swelling. Incisions were deepened through the fascial planes, and the radial artery controls were taken [Figure 2]. Further incision over the swelling and dissection isolated the arterial aneurysm and the adjacent cephalic venous aneurysm. The aneurysms were demonstrated just adjacent to the fistulous communication. Using deBakey clamps, the radial artery portions proximal and distal to the aneurysm were clamped, and the communicating arteriovenous aneurysms were resected. The vein was ligated off. The radial artery defect, approximately 4 cm long, was reconstructed with left great saphenous vein interposition graft [Figure 3].
Figure 2: Bridging the fascial layers between arterial and venous aneurysms

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Figure 3: Postradial artery reconstruction

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Postoperative specimen showed two separate communicating aneurysms, one of the radial artery and the other of the cephalic vein [Figure 4]. The radial artery aneurysm measured 4 cm × 3 cm × 3 cm, and the venous aneurysm measured 1.5 cm × 1 cm × 1 cm (L × W × H).
Figure 4: Aneurysmectomy specimen

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The patient was started on Aspirin postoperatively. A single follow-up has been done so far, patient is comfortable and wound is healthy.


  Discussion Top


Concomitant AVFs and pseudoaneurysms (PSA) of the arteries are uncommonly reported in the literature and are extremely rare presenting together. Trauma (primarily) and invasive vascular procedures such as cardiac catheterization, Fogarty's catheter balloon embolectomy, and IV cannulation carry a risk of such vascular complications at the puncture site.[2],[4] Very rare instances of a mutation in the COL3A1 gene of collagen 3 with a diagnosis of the vascular (Type 4) Ehlers-Danlos syndrome have been reported.[5] PSA arise from a disruption in the arterial wall, resulting in blood dissecting into the tissues around the artery, forming a perfused sac that is contained by the media or adventitia or simply by soft-tissue structures surrounding the injured vessel.[6] This (if we are dealing with femoral artery PSA) is the most common complication of cardiac catheterization, occurring in 0.2%–8% of cardiac cases.[7],[8] Duplex ultrasound, which consists of gray scale and color Doppler ultrasound, has proven to be an excellent noninvasive modality that provides not only anatomic but also hemodynamic information.[9] Clinical symptoms are usually swelling, pain in the groin, or a palpable pulsatile mass with a thrill or murmur.[10] Traumatic AVF are those fistulae caused by blunt or penetrating trauma, they are not iatrogenic. A rise in the number of iatrogenic AVF is attributed to the increasing number of interventional procedures being performed. As per literature studies, the natural history is relatively benign with 38%–81% closing spontaneously.[11] Lower limbs account for majority of the fistulae with the femoral artery accounting for 12%–30% of the AVF while the carotid and subclavian arteries account for 4%–25%.[12] Our case involving the radial artery and cephalic vein caused due to routine IV cannula insertion is not having any reference online. However, isolated reports involving a radiocephalic AVF but no aneurysm are available, one of them being secondary to IV cannula insertion for administering antibiotics for diverticulitis in a 79-year-old man, as reported by Williams and Sinha.[13]

Although digital subtraction arteriography is considered the gold standard, duplex scans, computed tomographic angiography, and magnetic resonance imaging provide faster and quicker diagnosis.[14] The aim of the treatment is to definitively close the direct communication between the artery and vein and resect the aneurysm. AVF is occasionally fatal; therefore, these fistulas are usually surgically repaired. Other options include endovascular stenting and embolization. Embolization is preferred when treating a complex AVF with multiple feeding and draining vessels while endovascular stenting is preferred in regions where access is difficult as in solid organ AVFs.


  Conclusion Top


In conclusion, I would like to reiterate that iatrogenic AVF with concomitant PSA of both the vessels is an extremely rare manifestation of iatrogenic vascular trauma. Care should be taken to ensure swift diagnosis and management of these lesions as they can occasionally be fatal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zakharkina MV, Chechetkin AO, Krotenkova MV, Konovalov RN. Ultrasound diagnostics of a spontaneous arteriovenous fistula of the head and neck. J Ultrason 2017;17:217-21.  Back to cited text no. 1
    
2.
Altin RS, Flicker S, Naidech HJ. Pseudoaneurysm and arteriovenous fistula after femoral artery catheterization: Association with low femoral punctures. AJR Am J Roentgenol 1989;152:629-31.  Back to cited text no. 2
    
3.
Ha JF, Hons M, Sieunarine K. Arteriovenous fistula secondary to recurrent metacarpophalangeal joint dislocation: A case report. Oschsner J 2009;9:14-6.  Back to cited text no. 3
    
4.
Fransson SG, Nylander E. Vascular injury following cardiac catheterization, coronary angiography, and coronary angioplasty. Eur Heart J 1994;15:232-5.  Back to cited text no. 4
    
5.
Ching KC, McCluskey KM, Srinivasan A. Peroneal arteriovenous fistula and pseudoaneurysm: an unusual presentation. Case Rep Vascular Med 2014;2014:506067.  Back to cited text no. 5
    
6.
Lamb K. Pseudoaneurysm and arteriovenous fistula simultaneously after cardiac catheterization. JDMS 2007;23:208-11.  Back to cited text no. 6
    
7.
Lenartova M, Tak T. Iatrogenic pseudoaneurysm of femoral artery: Case report and literature review. Clin Med Res 2003;1:243-7.  Back to cited text no. 7
    
8.
Madia C. Management trends for postcatheterization femoral artery pseudoaneurysms. JAAPA 2019;32:15-8.  Back to cited text no. 8
    
9.
Foshager MC, Finlay DE, Longley DG, Letourneau JG. Duplex and color Doppler sonography of complications after percutaneous interventional vascular procedures. Radiographics 1994;14:239-53.  Back to cited text no. 9
    
10.
Chun EJ. Ultrasonographic evaluation of complications related to transfemoral arterial procedures. Ultrasonography 2018;37:164-73.  Back to cited text no. 10
    
11.
Toursarkissian B, Allen BT, Petrinec D, Thompson RW, Rubin BG, Reilly JM, et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg 1997;25:803-8.  Back to cited text no. 11
    
12.
Zhou W. Acquired arteriovenous fistulae. In: Cronenwett JL, Johnston KW, editors. Rutherford: Vascular Surgery. 8th ed., Vol. 2. Philadelphia: Elsevier; 2014. p. 1274.  Back to cited text no. 12
    
13.
Williams AE, Sinha P. Arteriovenous fistula: A rare complication of peripheral venous cannulation and an example of the importance of clinical examination. Med Rep Case Stud 2016;1:1.  Back to cited text no. 13
    
14.
Nagpal K, Ahmed K, Cuschieri R. Diagnosis and management of acute traumatic arteriovenous fistula. Int J Angiol 2008;17:214-6.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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