Year: 2021
Type: article
Study design: Case Report
Abstract: A 78-year-old woman underwent radiofrequency catheter ablation for symptomatic paroxysmal atrial fibrillation. Three 8.5-Fr sheaths (SL0, St. Jude Medical, Plymouth, MN, USA) were inserted from the right common femoral vein (CFV) without ultrasound guidance,1 and pulmonary vein isolation was achieved. Her anticoagulation regimen, apixaban 5 mg twice daily, was skipped only on the procedure day. She was discharged with no apparent haematoma at the puncture site. On the fifth postoperative day, however, swelling around the puncture site and severe pain suddenly occurred. Computed tomography (CT) imaging showed the formation of a pseudoaneurysm in the superficial circumflex iliac artery (SCIA) that was accompanied by an arteriovenous fistula (AVF) connecting to the CFV (Figure 1). The neck of the pseudoaneurysm was not clearly detected by ultrasound at that time, and we applied ultrasound-guided compression repair while checking the blood flow of the AVF by colour Doppler.2 Just after release of the compression, she suddenly complained of severe pain again, and the femoral swelling rapidly worsened. Repeat CT imaging (Figure 2) showed that the AVF had disappeared, but the arterial bleeding that had formed the pseudoaneurysm was still active and had also formed a large subcutaneous haematoma. We recognized that the AVF unintentionally carried a drainage route of the pseudoaneurysmal bleeding to the CFV (downstream) and that elimination of only the AVF by compression without preventing arterial bleeding (upstream) was the cause of the expansion of bleeding. If the pseudoaneurysm had been resolved first, the AVF would have spontaneously disappeared. Emergent percutaneous coil embolization of the SCIA was performed that eliminated blood flow to the pseudoaneurysm (Videos 1and2). First computed tomography image during the arterial phase. A pseudoaneurysm was formed in the superficial circumflex iliac artery, and an arteriovenous fistula connected the pseudoaneurysm and common femoral vein. The common femoral vein was enhanced despite imaging in the arterial phase. The lengths of pseudoaneurysmal neck and arteriovenous fistula were 1.5 and 10.0 mm, respectively. AVF, arteriovenous fistula; CFA, common femoral artery; CFV, common femoral vein; PA, pseudoaneurysm; SCIA, superficial circumflex iliac artery. First computed tomography image during the arterial phase. A pseudoaneurysm was formed in the superficial circumflex iliac artery, and an arteriovenous fistula connected the pseudoaneurysm and common femoral vein. The common femoral vein was enhanced despite imaging in the arterial phase. The lengths of pseudoaneurysmal neck and arteriovenous fistula were 1.5 and 10.0 mm, respectively. AVF, arteriovenous fistula; CFA, common femoral artery; CFV, common femoral vein; PA, pseudoaneurysm; SCIA, superficial circumflex iliac artery. Second computed tomography image during the arterial phase. The arteriovenous fistula had disappeared, but the arterial bleeding that had formed the pseudoaneurysm was still active and had also formed a large subcutaneous haematoma. CFA, common femoral artery; PA, pseudoaneurysm; SCIA, superficial circumflex iliac artery. Second computed tomography image during the arterial phase. The arteriovenous fistula had disappeared, but the arterial bleeding that had formed the pseudoaneurysm was still active and had also formed a large subcutaneous haematoma. CFA, common femoral artery; PA, pseudoaneurysm; SCIA, superficial circumflex iliac artery. Emergency angiography was performed. The superficial circumflex iliac artery was selectively cannulated with a microcatheter, and a pseudoaneurysm was visualized. Emergency angiography was performed. The superficial circumflex iliac artery was selectively cannulated with a microcatheter, and a pseudoaneurysm was visualized. The superficial circumflex iliac artery was embolized with coils, and blood flow disappeared. The superficial circumflex iliac artery was embolized with coils, and blood flow disappeared. Ultrasound-guided compression is a non-invasive and effective strategy to repair an iatrogenic AVF and pseudoaneurym.2 However, the AVF should not be treated before haemostasis of the arterial bleeding that formed the pseudoaneurysm is obtained. Ultrasound-guided cannulation of the CFV is recommended to prevent this complication.1 We thank Drs Masaru Nemoto, Yoshiharu Enomoto, and Yasuyuki Suzuki for their assessment from the vascular surgical point of view. Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance. Conflict of interest: None declared. Funding: None declared.
Institutions: Ibaraki Prefectural Central Hospital, University of Tsukuba
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $726
OpenAlex ID: W3203044658