Peripheral Arteriovenous Fistula after Coronary Stenting

A 54-year-old woman was referred to us with malaise, anorexia, generalized edema, ascites, and abnormal liver function. Angiography had been performed 6 months earlier because of chest pain. At that time, direct stenting on the mid-portion of the left anterior descending coronary artery (LAD) was performed with a 3 × 8-mm Liberté® Bare-Metal Coronary Stent (Boston Scientific Corporation; Natick, Mass). The left circumflex and right coronary arteries were normal, and the patient had no cardiac risk factors. Two days after percutaneous coronary intervention, she was readmitted to the hospital with fever, low blood pressure, and other signs and symptoms of sepsis. Her blood culture was positive for Staphylococcus aureus, and she was given appropriate antibiotic agents for 2 weeks. She recovered and was discharged from the hospital but was readmitted twice during the next 5 to 6 months with signs and symptoms of liver failure, generalized edema, and ascites. She was treated for various possible conditions, including disseminated intravascular coagulopathy, inferior vena caval (IVC) thrombosis, and hepatitis.

A thorough physical examination at our center revealed a bruit in the hypogastric region. Computed tomographic angiography showed a large, right common iliac-to-IVC fistula.

Right femoral arterial access with an 8F sheath was used for introducing balloons and stents, and left femoral arterial access with a 6F pigtail catheter was used for the injection of contrast medium. After evaluating the fistula in different projections (Figs. 1 and 2), we deployed a 10 × 50-mm Hemobahn® Stent-Graft (W.L. Gore & Associates, Inc.; Putzbrunn, Germany) to the site of the fistula. Contrast medium showed a residual shunt proximal to our stent-graft (Fig. 3), and we did not have another one available. In the faint hope that the leakage was due to incomplete apposition, we inflated a 12 × 30-mm BIB® balloon (NuMED, Inc.; Nicholville, NY) to seal it; however, this attempt failed. We implanted another stent (an 8-zig, 28-mm-long, covered NuMed CP stent™) proximal to the 1st one, and the shunt disappeared (Fig. 4). The patient's signs and symptoms resolved, and she was doing well at her 6-month follow-up visit.

Fig. 1 Angiogram (anteroposterior view) with contrast medium in the distal abdominal aorta shows filling of both the iliac artery and the inferior vena cava.

Fig. 2 Angiogram (left anterior oblique view) shows the fistula and a protruding cavity (probably a pseudoaneurysm).

Fig. 3 Angiogram (left anterior oblique view) shows implantation of the 1st stent-graft (10 × 50-mm Hemobahn® [Gore]), which did not occlude the pseudoaneurysm; a residual shunt remained.

Fig. 4 The final result is shown on this angiogram (left anterior oblique view), obtained after implantation of another stent-graft (8-zig, 28-mm-long, covered NuMed CP stent™) proximal to the 1st one.

Comment

Peripheral arteriovenous fistula of the great vessels is a rare complication. In our patient, we think that arterial injury, caused by the sheath or catheters during the original angiography and intervention, resulted in a pseudoaneurysm, which most likely became mycotic and erupted when the patient had S. aureus septicemia. This eruption, in turn, may have led to the formation of the peripheral arteriovenous fistula.

Treatment of peripheral arteriovenous fistula of the great vessel is not well established. Our patient had a large, right common iliac--to-IVC fistula with a huge shunt. We successfully treated these conditions with 2 covered stents. To our knowledge, there has been no such case reported previously in the medical literature.