Radial Arteriovenous Fistula following Percutaneous Coronary Intervention: A Rare Case

J. Walter Dutton, M.D., West Virginia University School of Medicine, Morgantown WV W. Thomas McClellan, M.D., Plastic and Reconstructive Surgery, West Virginia University, Morgantown WV

Percutaneous coronary intervention (PCI) has traditionally been performed through a trans-femoral approach. However, trans-radial access has gained in popularity with interventional cardiologists due to its easy accessibility, quick ambulation, and shorter hospital stay.

Although PCI via trans-radial approach has advantages, it is not completely free of the complications experienced with the trans-femoral approach including hematoma, pseudoaneurysm, and pain.

Arteriovenous fistula (AVF) of the radial artery is rare complication with only five cases previously published worldwide. We report a case of arteriovenous fistula (AVF) occurring after coronary intervention using the trans-radial approach.

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A 61 year old female presented to the ED with increasing pain and paresthesias in her right dominant distal wrist and hand over the prior two months. Additionally, she was experiencing pain radiating up the arm and into the right shoulder. Coronary origin of pain was eliminated by medical team.

The patient had received a PCI with stenting of the left anterior descending artery three months prior to admission through the right radial artery at the wrist. Physical examination demonstrated a 2 cm superficial compressible mass with easily palpable thrill over the previous radial puncture site. There was normal arterial filling of the hand, an intact arch, and diminished sensibility in the median nerve distribution.

Duplex ultrasound confirmed an AVF between the distal radial artery and the adjacent venae commintants [Figure 1]. Operative exploration revealed an engorged mass with a tortuous proximal ulnar venae comitantes. Resection of the arteriovenous mass was performed with primary microvascular reanastomosis of the radial artery and ligation of veins [Figure 2]. Post operatively the patient had complete resolution of her radiating pain and parasthesias of the median nerve. At three month follow up the radial artery remained patent with preservation of antegrade flow.

Figure 1. Doppler ultrasound demonstrating continuous turbulent flow between radial artery and venae commintants

Figure 2. Intraoperative gross dissection visualizing fistula connecting radial artery and venae commitants

An arteriovenous fistula is an abnormal connection between an artery and vein resulting in a disrupted blood flow pattern. AVFs may occur congenitally, be surgically created for hemodialysis, or result from trauma or erosion of arterial annuerysm. Femoral AVFs are a well-documented complication of cardiac catheritization by femoral approach occurring at an incidence of approximately 1% in the modern era.

1, 2, 4 (see Video, Supplemental Digital

Content 1, which demonstrates Duplex ultrasound findings, intraoperative dissection and gross specimen post resection)

In contrast, AVFs of the radial artery following cathertization are exceedingly rare with only two previous reports published in English-language medical literature. Only small veins are present in the vicinity of the radial puncture site making AVFs in this region less likely than other vascular complications such as pseudoaneurysms. Duplex ultrasound is the preferred diagnostic tool for confirmation of AVFs. While radial artery AVFs are rare, its rapidly growing popularity for PCI suggests an increased incidence in the future and stresses the importance of clinical suspicion, proper diagnosis, and early surgical intervention.

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References

1. Min Seub Kwac, et al. A rare case of radial arteriovenous fistula after coronary angiography. Korean Circu J. 2010; 40: 677-679

2. Goldberg A, Tsipis A, Rosenfeld I. Arteriovenous fistula after cardiac catheritization from a radial approach. IMAJ 2013; 15: 381-382

3. Lee M S, Wolfe M, Stone G W. Transradial versus transfemoral percutaneous coronary intervention in acute coronary syndrome: re-evaluation of the current body of evidence. J Am Coll Cariol Intv 2013; 6: 1149-52

4. Perings SM, Kelm M, Jax T, Strauer BE. A prospective study on incidence and risk factors of arteriovenus fistula following transfemoral cardiac catheritization. Int J Cardiol 2003; 88: 223-8

Figure Legends

Figure 1. Doppler ultrasound demonstrating continuous turbulent flow between radial artery and venae commintants

Figure 2. Intraoperative gross dissection visualizing fistula connecting radial artery and venae commitants

Online Supplementary Materials

Video, Supplemental Digital Content 1. Pertinent Clinical and Intraoperative Findings Demonstrating Radial AVF. A video demonstrating Duplex ultrasound findings, intraoperative dissection and gross specimen post resection.