Recurrent Arteriovenous Fistula as a Rare Complication of Transradial Coronary Angiography

Coronary catheterization utilizing a radial access site as opposed to a femoral access site has been associated with many benefits, such as reduced cost, decreased mortality, and fewer complications in establishing arterial access.¹ Access site vascular complications, including groin hematoma, pseudoaneurysms, arteriovenous fistula (AVF), arterial dissection, arterial perforation, and neurological deficits, have all been shown to be significantly reduced via a transradial approach (TRA) as compared to the transfemoral approach.^2,3,4 Major bleeding following coronary artery catheterization remains an independent predicator of mortality.² Recent studies have yielded promising results, demonstrating bleeding risk reduction for TRA vs a transfemoral approach. The RIFLE-STEACS trial found a 47% reduction in the rate of access site-related bleeding complications, as well as an overall decrease in cardiac death.⁵ TRA has also gained favor with patients, as it is associated with increased comfort and a decreased time to ambulation following the procedure.

Iatrogenic AVF is a rare vascular complication that may result from coronary angiography. The incidence of AVF formation following a transfemoral approach has been well documented. However, there are far fewer reports discussing AVF formation following a transradial approach.^6,7 Furthermore, there is no general consensus regarding the management and treatment of AVF formation when radial access is utilized. Previous case studies have reported resolution of AVF following transradial catheterization with conservative treatment rather than a surgical intervention.² Here, we report a case of AVF as a complication of transradial coronary angiography that reoccurred after an initial resolution following conservative management, requiring further treatment with surgical embolization.

Case Presentation

A 58-year-old Caucasian male with cardiac risk factors including hypertension, stable angina, myocardial infarction, coronary artery disease, peripheral vascular disease, diastolic congestive heart failure, insulin-dependent diabetes mellitus, hyperlipidemia, and a 20 pack-year smoking history, presented to the emergency department with chest pain for one day. He described his chest pain as burning, retrosternal sensation radiating to his left jaw, associated with diaphoresis, nausea, and vomiting. He had undergone cardiac catheterization three years prior with placement of a drug-eluting stent in the left anterior descending (LAD) artery. Subsequent cardiac catheterization the same year showed a patent LAD stent. Previous echocardiography indicated left ventricular diastolic dysfunction with an ejection fraction of 55-60%. A recent stress test showed anteroseptal scarring with no ischemia. The patient was compliant with his medications, including aspirin 81 mg daily, clopidogrel 75 mg daily, atenolol 50 mg daily, diltiazem 120 mg daily, and losartan 25 mg daily. He was previously prescribed ranolazine 500 mg twice daily, but was non-adherent. Initial serial troponins were negative. An electrocardiogram (EKG) showed sinus rhythm at 98 bpm, left axis deviation, and nonspecific ST-T wave changes. The patient’s medications were optimized to include isosorbide mononitrate 60 mg daily and the atenolol was changed to metoprolol 75 mg twice daily. Despite optimization of his antianginal treatment, the patient continued to complain of persistent chest pain. A plan was subsequently made for coronary angiography to rule out obstructive coronary artery disease.

The Allen’s test, first described in 1929⁸, was first used to determine the presence of collateral flow in the hand. The radial and ulnar arteries were located by their pulses, and both arteries were compressed simultaneously by four fingers. During direct pressure, the patient was asked to clench and unclench his fist several times. He was then asked to relax his hand and extend his fingers into a slightly flexed position while pressure was maintained on the radial and ulnar arteries. His hand appeared blanched at this point. Pressure on the ulnar artery was relieved, while pressure continued to be applied on the radial artery. The return of color to the hand and fingers was noted in <5 seconds, indicating a normal Allen’s test. After confirming dual arterial supply of the palmar arch with a negative Allen’s test, coronary angiography was carried out using a 6 French, 23 cm radial sheath in the right radial artery. Findings were significant for mild to moderate non-obstructive coronary artery disease (CAD) of the distal LAD and mild to moderate restenosis of the previously placed drug-eluting stent in the proximal LAD. Bivalirudin was used for anticoagulation, with an initial bolus of 0.75 mg/kg, followed by 1.75 mg/kg/hr for the duration of the procedure. The radial artery sheath was immediately removed after completion of coronary angiography and hemostasis achieved by application of a radial compression bandage. The patient tolerated the procedure well without any complications. His chest pain was deemed to be multifactorial, attributed to chronic pain syndrome and esophagitis, and his antianginal treatment was optimized at the time. Post-op day three of cardiac catheterization, the patient complained of right wrist discomfort, described as achiness and warmth over the right radial catheterization access site. He denied numbness or finger claudication. An Allen’s test performed at the bedside was negative. An ultrasound with color Doppler imaging showed a fistulous connection between the radial artery and radial vein, demonstrating a biphasic waveform with a peak systolic velocity of 100.7 cm/s. A pressure device was used for conservative management of his AV fistula (Figure 1). A repeat ultrasound the next day showed resolution of the AV fistula (Figure 2). The patient was subsequently discharged home with optimized antianginal management. One month later, the patient returned to the hospital for recurrence of his chest pain and uncontrolled diabetes. During this visit, he again complained of warmth and achiness in his right wrist. Color Doppler ultrasound of wrist showed normal venous waveforms without definite fistula formation. There was no evidence of acute coronary syndrome (ACS) and patient was subsequently discharged home on the same medication regimen. Two months later, the patient was hospitalized with similar chest pain, which was determined to be due to chronic chest pain syndrome. No further cardiac workup was pursued. The patient once again complained of persistent pain in his right wrist. Physical exam findings demonstrated a good right radial pulse with the presence of bruit and no palpable thrill. Color Doppler ultrasound confirmed the formation of an AV fistula between the radial artery and radial vein (Figures 3-4). The patient subsequently underwent endovascular embolization of his right AV fistula. An Allen’s test after the procedure was negative. The patient tolerated the surgery well, with resolution of the AV fistula and all associated symptoms.

Discussion

Data collected from studies have suggested that the transradial approach (TRA) is associated with fewer bleeding complications, reduced cost, decreased hospital mortality, and fewer access site complications as compared to the transfemoral approach.¹ In the recent, prospective Radial Versus Femoral Randomized investigation in ST elevation Acute Coronary Syndrome (RIFLE-STEACS) trial, subjects with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous intervention (PPCI) were randomized between transfemoral and transradial access. RIFLE-STEACS enrolled 1001 patients across four Italian centers and found not only a 47% reduction in the rate of access site-related bleeding complications, but also a reduction in the rate of hospital stay and cardiac death with TRA.⁵ In another recent prospective registry of 507 patients undergoing TRA coronary catheterization, vascular complications were detected in 12 patients (2.36%), radial artery occlusion was detected in 9 patients (1.77%), 2 patients had pseudoaneurysms (0.38%), and 1 patient developed an AV fistula (0.19%).⁹ In the largest randomized trial to date comparing radial and femoral access, MATRIX (Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX study) included 8404 subjects with ACS undergoing intervention. In patients with non STEMI (NSTE)-ACS, the use of radial access significantly reduced both coprimary outcomes of net adverse clinical events (NACE) and MACE (death, myocardial infarction, or stroke), as well as all-cause and cardiac mortality. In patients presenting with STEMI, the use of radial access did not formally reduce all-cause or cardiac mortality.¹⁰ Interestingly, a similar study, the RIVAL (Radial vs Femoral Access of Coronary Intervention) trial, compared TRA with transfemoral access in 7021 patients presenting with ACS. The primary outcome, as in the MATRIX trial, was defined as MACE (a composite of death, myocardial infarction, stroke, or non-coronary artery bypass graft surgery-related major bleeding within 30 days). Although incidence of the primary outcome was not significantly different between the radial and femoral approaches, major vascular complications, defined as large hematoma, AVF, ischemic limb needing surgery, and pseudoaneurysm, occurred in 1.4% of subjects with TRA as compared to 3.8% of subjects with transfemoral access (P<.001). In the RIVAL study, none of the 3507 patients in the TRA group were reported to have an AV fistula, whereas 5 (0.14%) of 3514 subjects in transfemoral access group had an AV fistula.¹¹

Iatrogenic post-catheterization femoral AV fistula is not uncommon. A puncture below the common femoral artery is the main culprit of post-catheterization AV fistulas.⁶ The incidence is higher in therapeutic compared to diagnostic catheterization (0.87% vs 0.15%).^12,13 AV fistula formation with TRA is rare and has been infrequently reported.⁷ Iatrogenic AV fistulas result from penetration of a needle through an arterial and venous tributary during angiographic catheterization procedures. Rarely, when the communication between the artery and vein does not seal spontaneously, an AV fistula forms. Incidence of iatrogenic AV fistula formation can be minimized by operator experience, using a sheath size smaller than arterial diameter, and limiting repeated access of the same artery. There is a trend toward longer sheaths (23-25 cm), because of the concern of forearm radial spasm. The radial artery is most commonly cannulated with a standard 5 or 6 French radial artery sheath. The ideal ratio of inner diameter of radial artery to sheath-out diameter has been found to be 0.9. Using sheath diameters greater than the radial artery diameter should be avoided.¹⁴ Sheaths with smaller diameter are associated with a reduction in both pain experienced by patients and incidence of radial artery spam.¹⁵ Furthermore, ultrasound-guided needle placement can be helpful in providing anatomical information such as the proximity of the radial artery to the vein. The largest study to date on incidence and clinical outcomes of AV fistulas found that predictors of AV fistula formation were puncture of left groin, female gender, arterial hypertension, coumadin therapy, and high heparin dosage during the procedure.¹⁶ Our patient had none of these risk factors and his right radial artery was accessed after the first procedure without any complications.

The prognosis of an uncomplicated AV fistula is usually good. Post-catheterization AV fistulas are not generally life-threatening and close spontaneously. They are associated with serious complications such as high output cardiac failure with a large AV fistula, aneurysm degeneration of the artery, and limb edema.¹⁷ In large AV fistulas, significant hemodynamic shift can occur from the high systemic vascular resistance in the artery to the lower resistance in the vein. Increased venous return increases stroke volume, which can potentiate high-output heart failure. In the setting of preexisting peripheral vascular disease, high-flow AV fistulas can reduce blood flow to the lower extremity, which can lead to the onset or worsening of lower extremity ischemic symptoms.¹⁸ In a study of 81 lower-extremity AV fistulas, 46 (81%) of 57 patients not requiring immediate surgical repair had spontaneous resolution of the AV fistula within an average mean of 23 days.¹⁹ In another prospective study, the incidence of AV fistulas was 0.86% (n=88) among a total of 10,271 consecutive patients undergoing cardiac catheterization over a period of three years. Within 12 months, 38% of all AV fistulas closed spontaneously.¹⁶

Patients with a persistent iatrogenic AV fistula can be managed conservatively, medically, or surgically. Conservative management with observation remains a viable option for femoral AV fistulas, as most femoral AV fistulas will close spontaneously. Implantation of a covered stent can be used for the femoral artery.^20,21 As our patient underwent TRA catheterization, a stent would be a poor choice, given the small size of the artery and the possibility of restenosis. Continuous low-pressure compression using a hemostatic band can be implemented for radial AV fistula following TRA²², and a pressure device was initially used for conservative, noninvasive treatment in our patient. While a surgical repair approach has been advocated as the intervention of choice for cases of AV fistula resulting from TRA^19,23, surgical options depend on the size of AV fistula and include surgical ligation, excision, and repair. This is an invasive option associated with operative morbidity and mortality. Post-catheterization femoral AV fistulas have been treated successfully with percutaneous and endovascular embolization.^24,25 To our knowledge, this is the first reported case of iatrogenic TRA AV fistula managed successfully with endovascular embolization. It further challenges the practice that AV fistulae arising from use of the TRA approach need to be addressed either surgically or conservatively.^7,23

Conclusion

Iatrogenic AV fistula is a rare vascular complication of transradial coronary angiography that can potentially be treated with embolization rather than conservative management or surgical intervention. Our case demonstrates that endovascular or percutaneous embolization can be a superior alternative to conservative or surgical management for a radial AV fistula. In addition, TRA catheterization cases of AV fistula that are first managed conservatively with a pressure device can be repaired with embolization versus surgical intervention. 

Disclosures: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Sheharyar Minhas, MD, at sminhas7@yahoo.com.
 

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