A 76-year-old man presented with progressive abdominal distention and lower limb oedema despite increasing doses of diuretic therapy, which started after a left-side antegrade ventricular tachycardia (VT) ablation procedure.
His past medical history included an ischaemic mid-range ejection fraction heart failure; internal cardioverter-defibrillator implantation for monomorphic VT; mitral annuloplasty and permanent atrial fibrillation.
On admission, he had a 3/6 grade mid-systolic murmur throughout the precordium, jugular venous distention, non-tense ascites and bilateral 2+ grade pitting oedema up to the thighs. Additionally, a right groin thrill was palpable.
Notwithstanding intravenous sequential nephron blockade therapy, there was no clinical improvement.
The echocardiogram revealed de novo dilated and mildly dysfunctional right ventricle (RV) with signs of volume overload (Figure 1), severe tricuspid regurgitation, and severe pulmonary hypertension (Supplementary material online). There were no changes concerning left-side disease.
Figure 1.
Pre-procedure echocardiogram (parasternal short-axis view) showing signs of volume overload.
A cause–effect relationship hypothesis was raised by the temporal relation with the VT ablation procedure and the presence of a right groin thrill.
A computed tomography angiogram shown a large right-sided femoro-femoral arteriovenous fistulas between the common femoral artery and common femoral vein (Supplementary material online).
The patient subsequently underwent successful percutaneous fistula exclusion with implantation of a vascular endoprosthesis (Viabahn, Gore Medical® 7/50 mm) in the common femoral artery (Figure 2, Supplementary material online).
Figure 2.
Peripheral angiography demonstrating femoro-femoral arteriovenous fistulas (white arrow = common femoral artery; lightning = arteriovenous fistulas; black arrow = common femoral vein).
Afterwards, there was a significant and consistent clinical improvement—after 6 months, he remained without congestive symptoms with a total weight loss of 15 kg, despite ambulatory diuretics reduction. Post-procedure echocardiogram showed an improvement in RV function and volume overload signs (Supplementary material online).
Arteriovenous fistulas are potentially harmful complications of cardiac catheterization that can lead to pulmonary hypertension and congestive heart failure in susceptible patients.1 Although watchful waiting and ultrasound-guided compression are the first-line therapeutic options, spontaneous closure is less likely to occur in anti-coagulated patients.2 These complications can be managed by endovascular exclusion using arterial covered stents with high technical success, thus avoiding vascular open surgery.3
Supplementary material
Supplementary material is available at European Heart Journal - Case Reports online.
Slide sets: A fully edited slide set detailing this case and suitable for local presentation is available online as Supplementary data.
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.
Supplementary Material
References
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