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Radial Arteriovenous Fistula following Percutaneous Coronary Intervention: A Rare Case

Dutton, J. Walter M.D.; McClellan, W. Thomas M.D.

Plastic and Reconstructive Surgery: September 2014 - Volume 134 - Issue 3 - p 495e–497e
doi: 10.1097/PRS.0000000000000481
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West Virginia University School of Medicine

Plastic and Reconstructive Surgery, West Virginia University, Morgantown, W.Va.

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Correspondence to Dr. McClellan, Division of Plastic Surgery, West Virginia University, 1085 Van Vorrhis Road, Suite 350, Morgantown, W.Va. 26505, wtmcclellan@hotmail.com

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Sir:

Percutaneous coronary intervention has traditionally been performed through a transfemoral approach. However, transradial access has increased in popularity with interventional cardiologists because of its easy accessibility, quick ambulation, and shorter hospital stay.

Although percutaneous coronary intervention through the transradial approach has advantages, it is not completely free of the complications experienced with the transfemoral approach, including hematoma, pseudoaneurysm, and pain. Arteriovenous fistula of the radial artery is a rare complication, with only five cases previously published worldwide. We report a case of arteriovenous fistula occurring after coronary intervention using the transradial approach.1–3

A 61-year-old woman presented to the emergency department with increasing pain and paresthesias in her right dominant distal wrist and hand over the prior 2 months. In addition, she was experiencing pain radiating up the arm and into the right shoulder. A coronary origin of pain was eliminated by the medical team.

The patient had received a percutaneous coronary intervention with stenting of the left anterior descending artery 3 months before 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 arteriovenous fistula between the distal radial artery and the adjacent venae comitantes (Fig. 1). Operative exploration revealed an engorged mass with a tortuous proximal ulnar vena comitans. Resection of the arteriovenous mass was performed with primary microvascular reanastomosis of the radial artery and ligation of veins (Fig. 2). Postoperatively, the patient had complete resolution of her radiating pain and paresthesias of the median nerve. At 3-month follow-up, the radial artery remained patent, with preservation of antegrade flow.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

An arteriovenous fistula is an abnormal connection between an artery and vein resulting in a disrupted blood flow pattern. Arteriovenous fistulas may occur congenitally, be surgically created for hemodialysis, or result from trauma or erosion of an arterial aneurysm. Femoral arteriovenous fistulas are a well-documented complication of cardiac catheterization by a femoral approach, occurring at an incidence of approximately 1 percent in the modern era.1,2,4 (SeeVideo, Supplemental Digital Content 1, which shows pertinent clinical and intraoperative findings demonstrating radial arteriovenous fistula. This video demonstrates duplex asound findings, intraoperative dissection, and gross specimen following resection, http://links.lww.com/PRS/B73.)

Video

Video

In contrast, arteriovenous fistulas of the radial artery following catheterization are exceedingly rare, with only two previous reports published in the English-language medical literature. Only small veins are present in the vicinity of the radial puncture site, making arteriovenous fistulas in this region less likely than other vascular complications such as pseudoaneurysms. Duplex ultrasound is the preferred diagnostic tool for confirmation of arteriovenous fistulas. Although radial artery arteriovenous fistulas are rare, the rapidly growing popularity of percutaneous coronary intervention suggests an increased incidence in the future and stresses the importance of clinical suspicion, proper diagnosis, and early surgical intervention.1–4

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

J. Walter Dutton, M.D.

West Virginia University School of Medicine

W. Thomas McClellan, M.D.

Plastic and Reconstructive Surgery

West Virginia University

Morgantown, W.Va.

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REFERENCES

1. Kwac MS, Yoon SJ, Oh SJ, Jeon DW, Kim DH, Yang JY. A rare case of radial arteriovenous fistula after coronary angiography. Korean Circ J. 2010;40:677–679
2. Goldberg A, Tsipis A, Rosenfeld I. Arteriovenous fistula after cardiac catheterization from a radial approach. Isr Med Assoc J. 2013;15:381–382
3. Lee MS, Wolfe M, Stone GW. Transradial versus transfemoral percutaneous coronary intervention in acute coronary syndrome: Re-evaluation of the current body of evidence. JACC Cardiovasc Interv. 2013;6:1149–1152
4. Perings SM, Kelm M, Jax T, Strauer BE. A prospective study on incidence and risk factors of arteriovenous fistulae following transfemoral cardiac catheterization. Int J Cardiol. 2003;88:223–228
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