Case Report
Two cases of arteriovenous fistula formation between the external iliac vessels following endovenous laser therapy
Vascular 2014, Vol. 22(6) 464–467 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114524394 vas.sagepub.com
MD Wheatcroft1, TF Lindsay2 and A Lossing1
Abstract Minimally invasive treatment of varicose veins is becoming increasingly popular with both patients and physicians. Endovenous laser therapy has been shown to be safe and effective but the rare complication of iatrogenic creation of arteriovenous fistulas has been described. One case of fistulation between the external iliac artery and vein has been published. We report two further cases and describe their management.
Keywords Endovenous laser therapy, endovenous, fistula, varicose
Introduction Varicose veins affect up to one-third of the adult population,1 produce a variety of symptoms and reduce the quality of life of those affected.2, 3 The great saphenous vein (GSV) is most frequently affected and until recently, the gold standard treatment has been ligation and division of the saphenofemoral junction (SFJ) with stripping of the thigh segment and multiple phlebectomies. Recently, minimally invasive techniques such as endovenous ablation with either laser (endovenous laser therapy (EVLT)) or radiofrequency ablation (RFA) energy have become increasingly popular with both patients and physicians. They can be performed under local anesthesia in an outpatient clinic, patients experience less post-operative pain with a quicker return to normal activity and work,4 and the lack of a groin wound eliminates the associated morbidity seen in open cases. Long-term follow-up data are still unavailable, but recurrence rates are similar to open surgery.5 Although EVLT has been shown to be safe,6 one case of iatrogenic arteriovenous (AV) fistula between the external iliac vein (EIV) and external iliac artery (EIA) has been reported.7 We report two further cases and describe their management.
Case 1 A 62-year-old male presented with progressive exertional dyspnoea of 2 years duration. Clinical examination revealed a thrill and bruit over the left femoral
vessels. An ECG showed left ventricular (LV) hypertrophy which was confirmed by echocardiogram, with an LV end diastolic diameter of 63 mm (normal 56 mm), increased left atrial (LA) diameter of 47 mm (normal 40 mm) and mild to moderate mitral regurgitation. He was referred to a vascular surgeon who elucidated that the symptoms began after EVLT of left GSV varicose veins, performed at another institution 3 years earlier. A duplex scan showed a high-flow AV fistula between the distal EIA and EIV. A computed tomography (CT) angiogram showed dilatation of the left EIA (diameter 2 cm) and EIV (diameter 4 cm) (see Figure 1). The diameter of the fistula was 1.2 cm. The large diameter of the EIA and the proximity of the fistula to the inguinal ligament precluded endovascular treatment. The patient therefore underwent open repair via a transverse lower left quadrant incision and a retroperitoneal approach. A longitudinal arteriotomy was made in the EIA, exposing the fistula which was then closed with a continuous 5/0 prolene suture. The patient’s intraoperative cardiac output was 12 l/min prior to fistula closure and decreased to 8 l/min following closure. The patient 1 Division of Vascular Surgery, University of Toronto and St Michael’s Hospital, Toronto, ON, Canada 2 Division of Vascular Surgery, University of Toronto and Toronto General Hospital, Toronto, ON, Canada
Corresponding author: MD Wheatcroft, University of Toronto and St Michael’s Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. Email: [email protected]
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Figure 1 CT angiogram of case 1 in axial (a) and coronal (b) projections. The enlarged external iliac artery (a) and external iliac vein (v) are marked. The connecting fistula can be seen (white arrow).
made an uneventful recovery and follow-up echocardiogram showed an improvement in LV end diastolic diameter to 59 mm, LA diameter 40 mm and only trivial mitral regurgitation. A repeat ECG showed a reduction in R wave amplitude. The patient has remained asymptomatic and although initial follow-up duplex scan showed no change in arterial dimensions and no AV fistula, at 18 months, there was a small recurrent fistula identified at the site of previous repair.
Prior to EVLT, both patients had symptomatic (painful) varicosities with no history of chronic venous skin changes or ulceration. They had normal body mass index and no history of any prior interventions or trauma. Pre-EVLT imaging, clinical and operative notes for the EVLT procedures were not available to us as they had been performed at private clinics. Neither patient had symptoms or history suggestive of post-EVLT deep vein thrombosis; however, this cannot be categorically excluded as follow-up duplex was not performed.
Case 2 A 39-year-old male presented with left leg swelling and heaviness following EVLT of GSV varicose veins at another institution 2 years previously. Clinical examination revealed an edematous left leg with a thrill and bruit over the left femoral vessels. A transfemoral angiogram confirmed an AV fistula measuring approximately 0.8 cm diameter between the EIA and EIV. The EIV was dilated to 2.5 cm whereas the diameter of the EIA was 1.2 cm. Both open and endovascular treatment were discussed with the patient and the latter chosen as the preferred therapeutic modality. Under a general anesthetic a cut down onto the left common femoral artery was performed. A 14 F sheath was then inserted and an angiogram performed. The fistula, the level of the inguinal ligament and the origin of the internal iliac artery were marked and a 13 mm 50 mm Viabahn stent (W. L. Gore & Associates, Inc., Flagstaff, Arizona) inserted and deployed. A completion angiogram confirmed occlusion of the fistula (see Figure 2). The patient was discharged the following day but suffered a minor lymph leak from the groin wound. At 12-month follow-up, the patient was asymptomatic and duplex scan showed a widely patent stent with no fistula.
Discussion EVLT is a percutaneous treatment performed under tumescent local anesthesia. Using ultrasound guidance, the distal truncal saphenous vein is cannulated and a laser probe inserted with the tip positioned 1–2 cm distal to the SFJ. The laser is then activated, producing 12–14 watts, and when withdrawn at 1 cm/5 s, will deliver an optimal 60–70 J/cm of vein. The laser energy heats the blood and vessel endothelium causing thrombotic and fibrotic occlusion of the vein. Clear ultrasound identification of the probe position relative to the SFJ is of vital importance to avoid injury to, or protrusion of thrombus into, the common femoral vein. Tumescent anesthesia not only makes the procedure tolerable to the patient but also protects structures normally adjacent to the GSV by physically separating the tissues and, in addition, acts as a heat sink. It also compresses the vein, reducing its diameter. Although EVLT is, in general, a safe procedure when performed by adequately trained surgeons, a total of 14 iatrogenic AV fistulas (including the two cases described here) are reported in the literature; 10 due to EVLT7–11 and 4 due to RFA.12–14 Most describe small fistulas involving either the greater or lesser
Downloaded from vas.sagepub.com by guest on July 27, 2015
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Vascular 22(6)
Figure 2 Intraoperative angiograms of case 2. The initial angiogram (a) shows the EIA and EIV and the fistula connecting them (black arrow). Fluoroscopic image (b) showing deployed Viabahn stent (black arrow). Completion angiogram (c) showing successful exclusion of the AV fistula. EIA: external iliac artery; EIV: external iliac vein; AV: arteriovenous.
saphenous veins. To our knowledge, there is only one other reported case of fistulation occurring within the iliac system.7 This case was also successfully treated with a Viabahn stent. External iliac fistulation due to EVLT is likely caused by inadvertent advancement of the probe through the SFJ into the EIV with either mechanical perforation through the vein into the artery, or vessel wall damage due to activation of the laser while still within the EIV. The lack of tumescent anesthesia at this level likely increases the risk of damaging the arterial wall. Intermittent or slow pullback technique causing uneven delivery of energy has also been linked to nerve damage and fistula creation.9 Open surgery on the iliac vessels in the presence of a high-flow fistula has the potential for major blood loss, and therefore endovascular stenting is an attractive alternative. However, stenting may not be technically feasible due to the large size of the EIA. Moreover, the long-term results of EIA stenting close to the inguinal ligament in young patients are unavailable and it remains to be seen whether stent-induced neointimal hyperplasia, stent migration or fracture will become problematic.
Conclusion Iliac AV fistulas appear to be a rare but serious complication of EVLT. They can develop high flows and
result in high-output cardiac failure in previously fit people. Adequate training emphasizing the importance of clear identification of probe position during insertion and prior to activation of the energy source is vital. A preliminary measurement and marking of the catheter using external landmarks such as the inguinal ligament and the intended site of cannulation could be used to determine the maximum permitted distance of insertion. Routine palpation and auscultation of the inguinal region at follow-up may help detect pathology early. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest No conflict of interest declared.
References 1. Allan PL, Bradbury AW, Evans CJ, et al. Patterns of reflux and severity of varicose veins in the general population – Edinburgh vein study. Eur J Vasc Endovasc Surg: Off J Eur Soc Vasc Surg 2000; 20: 470–477. 2. Kaplan RM, Criqui MH, Denenberg JO, et al. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg 2003; 37: 1047–1053.
Downloaded from vas.sagepub.com by guest on July 27, 2015
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3. Kurz X, Lamping DL, Kahn SR, et al. Do varicose veins affect quality of life? Results of an international population-based study. J Vasc Surg 2001; 34: 641–648. 4. Carradice D, Mekako AI, Mazari FA, et al. Randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins. Br J Surg 2011; 98: 501–510. 5. Brar R, Nordon IM, Hinchliffe RJ, et al. Surgical management of varicose veins: meta-analysis. Vascular 2010; 18: 205–220. 6. Darwood RJ and Gough MJ. Endovenous laser treatment for uncomplicated varicose veins. Phlebology 2009; 24(Suppl 1): 50–61. 7. Ziporin SJ, Ifune CK, MacConmara MP, et al. A case of external iliac arteriovenous fistula and high-output cardiac failure after endovenous laser treatment of great saphenous vein. J Vasc Surg 2010; 51: 715–719. 8. Theivacumar NS and Gough MJ. Arterio-venous fistula following endovenous laser ablation for varicose veins. Eur J Vasc Endovasc Surg: Off J Eur Soc Vasc Surg 2009; 38: 234–236.
9. Timperman PE. Arteriovenous fistula after endovenous laser treatment of the short saphenous vein. J Vasc Interv Radiol 2004; 15: 625–627. 10. Yildirim E, Saba T, Ozulku M, et al. Treatment of an unusual complication of endovenous laser therapy: multiple small arteriovenous fistulas causing complete recanalization. Cardiovasc Intervent Radiol 2009; 32: 166–168. 11. Vaz C, Matos A, Oliveira J, et al. Iatrogenic arteriovenous fistula following endovenous laser therapy of the short saphenous vein. Ann Vasc Surg 2009; 23: 412 e415–417. 12. Ahmad A, Sajjanshetty M, Mandal A, et al. Early arteriovenous fistula after radiofrequency ablation of long saphenous vein. Phlebology 2013; 28(8): 438–440. 13. Rudarakanchana N, Berland TL, Chasin C, et al. Arteriovenous fistula after endovenous ablation for varicose veins. J Vasc Surg 2012; 55: 1492–1494. 14. Martin EC and Todd GJ. Embolization of an arteriovenous fistula after radiofrequency ablation (RFA) of the saphenous vein. Cardiovasc Intervent Radiol 2010; 33: 227–228.
Downloaded from vas.sagepub.com by guest on July 27, 2015
Two cases of arteriovenous fistula formation between the external iliac vessels following endovenous laser therapy
Vascular 2014, Vol. 22(6) 464–467 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114524394 vas.sagepub.com
MD Wheatcroft1, TF Lindsay2 and A Lossing1
Abstract Minimally invasive treatment of varicose veins is becoming increasingly popular with both patients and physicians. Endovenous laser therapy has been shown to be safe and effective but the rare complication of iatrogenic creation of arteriovenous fistulas has been described. One case of fistulation between the external iliac artery and vein has been published. We report two further cases and describe their management.
Keywords Endovenous laser therapy, endovenous, fistula, varicose
Introduction Varicose veins affect up to one-third of the adult population,1 produce a variety of symptoms and reduce the quality of life of those affected.2, 3 The great saphenous vein (GSV) is most frequently affected and until recently, the gold standard treatment has been ligation and division of the saphenofemoral junction (SFJ) with stripping of the thigh segment and multiple phlebectomies. Recently, minimally invasive techniques such as endovenous ablation with either laser (endovenous laser therapy (EVLT)) or radiofrequency ablation (RFA) energy have become increasingly popular with both patients and physicians. They can be performed under local anesthesia in an outpatient clinic, patients experience less post-operative pain with a quicker return to normal activity and work,4 and the lack of a groin wound eliminates the associated morbidity seen in open cases. Long-term follow-up data are still unavailable, but recurrence rates are similar to open surgery.5 Although EVLT has been shown to be safe,6 one case of iatrogenic arteriovenous (AV) fistula between the external iliac vein (EIV) and external iliac artery (EIA) has been reported.7 We report two further cases and describe their management.
Case 1 A 62-year-old male presented with progressive exertional dyspnoea of 2 years duration. Clinical examination revealed a thrill and bruit over the left femoral
vessels. An ECG showed left ventricular (LV) hypertrophy which was confirmed by echocardiogram, with an LV end diastolic diameter of 63 mm (normal 56 mm), increased left atrial (LA) diameter of 47 mm (normal 40 mm) and mild to moderate mitral regurgitation. He was referred to a vascular surgeon who elucidated that the symptoms began after EVLT of left GSV varicose veins, performed at another institution 3 years earlier. A duplex scan showed a high-flow AV fistula between the distal EIA and EIV. A computed tomography (CT) angiogram showed dilatation of the left EIA (diameter 2 cm) and EIV (diameter 4 cm) (see Figure 1). The diameter of the fistula was 1.2 cm. The large diameter of the EIA and the proximity of the fistula to the inguinal ligament precluded endovascular treatment. The patient therefore underwent open repair via a transverse lower left quadrant incision and a retroperitoneal approach. A longitudinal arteriotomy was made in the EIA, exposing the fistula which was then closed with a continuous 5/0 prolene suture. The patient’s intraoperative cardiac output was 12 l/min prior to fistula closure and decreased to 8 l/min following closure. The patient 1 Division of Vascular Surgery, University of Toronto and St Michael’s Hospital, Toronto, ON, Canada 2 Division of Vascular Surgery, University of Toronto and Toronto General Hospital, Toronto, ON, Canada
Corresponding author: MD Wheatcroft, University of Toronto and St Michael’s Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. Email: [email protected]
Downloaded from vas.sagepub.com by guest on July 27, 2015
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Figure 1 CT angiogram of case 1 in axial (a) and coronal (b) projections. The enlarged external iliac artery (a) and external iliac vein (v) are marked. The connecting fistula can be seen (white arrow).
made an uneventful recovery and follow-up echocardiogram showed an improvement in LV end diastolic diameter to 59 mm, LA diameter 40 mm and only trivial mitral regurgitation. A repeat ECG showed a reduction in R wave amplitude. The patient has remained asymptomatic and although initial follow-up duplex scan showed no change in arterial dimensions and no AV fistula, at 18 months, there was a small recurrent fistula identified at the site of previous repair.
Prior to EVLT, both patients had symptomatic (painful) varicosities with no history of chronic venous skin changes or ulceration. They had normal body mass index and no history of any prior interventions or trauma. Pre-EVLT imaging, clinical and operative notes for the EVLT procedures were not available to us as they had been performed at private clinics. Neither patient had symptoms or history suggestive of post-EVLT deep vein thrombosis; however, this cannot be categorically excluded as follow-up duplex was not performed.
Case 2 A 39-year-old male presented with left leg swelling and heaviness following EVLT of GSV varicose veins at another institution 2 years previously. Clinical examination revealed an edematous left leg with a thrill and bruit over the left femoral vessels. A transfemoral angiogram confirmed an AV fistula measuring approximately 0.8 cm diameter between the EIA and EIV. The EIV was dilated to 2.5 cm whereas the diameter of the EIA was 1.2 cm. Both open and endovascular treatment were discussed with the patient and the latter chosen as the preferred therapeutic modality. Under a general anesthetic a cut down onto the left common femoral artery was performed. A 14 F sheath was then inserted and an angiogram performed. The fistula, the level of the inguinal ligament and the origin of the internal iliac artery were marked and a 13 mm 50 mm Viabahn stent (W. L. Gore & Associates, Inc., Flagstaff, Arizona) inserted and deployed. A completion angiogram confirmed occlusion of the fistula (see Figure 2). The patient was discharged the following day but suffered a minor lymph leak from the groin wound. At 12-month follow-up, the patient was asymptomatic and duplex scan showed a widely patent stent with no fistula.
Discussion EVLT is a percutaneous treatment performed under tumescent local anesthesia. Using ultrasound guidance, the distal truncal saphenous vein is cannulated and a laser probe inserted with the tip positioned 1–2 cm distal to the SFJ. The laser is then activated, producing 12–14 watts, and when withdrawn at 1 cm/5 s, will deliver an optimal 60–70 J/cm of vein. The laser energy heats the blood and vessel endothelium causing thrombotic and fibrotic occlusion of the vein. Clear ultrasound identification of the probe position relative to the SFJ is of vital importance to avoid injury to, or protrusion of thrombus into, the common femoral vein. Tumescent anesthesia not only makes the procedure tolerable to the patient but also protects structures normally adjacent to the GSV by physically separating the tissues and, in addition, acts as a heat sink. It also compresses the vein, reducing its diameter. Although EVLT is, in general, a safe procedure when performed by adequately trained surgeons, a total of 14 iatrogenic AV fistulas (including the two cases described here) are reported in the literature; 10 due to EVLT7–11 and 4 due to RFA.12–14 Most describe small fistulas involving either the greater or lesser
Downloaded from vas.sagepub.com by guest on July 27, 2015
466
Vascular 22(6)
Figure 2 Intraoperative angiograms of case 2. The initial angiogram (a) shows the EIA and EIV and the fistula connecting them (black arrow). Fluoroscopic image (b) showing deployed Viabahn stent (black arrow). Completion angiogram (c) showing successful exclusion of the AV fistula. EIA: external iliac artery; EIV: external iliac vein; AV: arteriovenous.
saphenous veins. To our knowledge, there is only one other reported case of fistulation occurring within the iliac system.7 This case was also successfully treated with a Viabahn stent. External iliac fistulation due to EVLT is likely caused by inadvertent advancement of the probe through the SFJ into the EIV with either mechanical perforation through the vein into the artery, or vessel wall damage due to activation of the laser while still within the EIV. The lack of tumescent anesthesia at this level likely increases the risk of damaging the arterial wall. Intermittent or slow pullback technique causing uneven delivery of energy has also been linked to nerve damage and fistula creation.9 Open surgery on the iliac vessels in the presence of a high-flow fistula has the potential for major blood loss, and therefore endovascular stenting is an attractive alternative. However, stenting may not be technically feasible due to the large size of the EIA. Moreover, the long-term results of EIA stenting close to the inguinal ligament in young patients are unavailable and it remains to be seen whether stent-induced neointimal hyperplasia, stent migration or fracture will become problematic.
Conclusion Iliac AV fistulas appear to be a rare but serious complication of EVLT. They can develop high flows and
result in high-output cardiac failure in previously fit people. Adequate training emphasizing the importance of clear identification of probe position during insertion and prior to activation of the energy source is vital. A preliminary measurement and marking of the catheter using external landmarks such as the inguinal ligament and the intended site of cannulation could be used to determine the maximum permitted distance of insertion. Routine palpation and auscultation of the inguinal region at follow-up may help detect pathology early. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest No conflict of interest declared.
References 1. Allan PL, Bradbury AW, Evans CJ, et al. Patterns of reflux and severity of varicose veins in the general population – Edinburgh vein study. Eur J Vasc Endovasc Surg: Off J Eur Soc Vasc Surg 2000; 20: 470–477. 2. Kaplan RM, Criqui MH, Denenberg JO, et al. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg 2003; 37: 1047–1053.
Downloaded from vas.sagepub.com by guest on July 27, 2015
Wheatcroft et al.
467
3. Kurz X, Lamping DL, Kahn SR, et al. Do varicose veins affect quality of life? Results of an international population-based study. J Vasc Surg 2001; 34: 641–648. 4. Carradice D, Mekako AI, Mazari FA, et al. Randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins. Br J Surg 2011; 98: 501–510. 5. Brar R, Nordon IM, Hinchliffe RJ, et al. Surgical management of varicose veins: meta-analysis. Vascular 2010; 18: 205–220. 6. Darwood RJ and Gough MJ. Endovenous laser treatment for uncomplicated varicose veins. Phlebology 2009; 24(Suppl 1): 50–61. 7. Ziporin SJ, Ifune CK, MacConmara MP, et al. A case of external iliac arteriovenous fistula and high-output cardiac failure after endovenous laser treatment of great saphenous vein. J Vasc Surg 2010; 51: 715–719. 8. Theivacumar NS and Gough MJ. Arterio-venous fistula following endovenous laser ablation for varicose veins. Eur J Vasc Endovasc Surg: Off J Eur Soc Vasc Surg 2009; 38: 234–236.
9. Timperman PE. Arteriovenous fistula after endovenous laser treatment of the short saphenous vein. J Vasc Interv Radiol 2004; 15: 625–627. 10. Yildirim E, Saba T, Ozulku M, et al. Treatment of an unusual complication of endovenous laser therapy: multiple small arteriovenous fistulas causing complete recanalization. Cardiovasc Intervent Radiol 2009; 32: 166–168. 11. Vaz C, Matos A, Oliveira J, et al. Iatrogenic arteriovenous fistula following endovenous laser therapy of the short saphenous vein. Ann Vasc Surg 2009; 23: 412 e415–417. 12. Ahmad A, Sajjanshetty M, Mandal A, et al. Early arteriovenous fistula after radiofrequency ablation of long saphenous vein. Phlebology 2013; 28(8): 438–440. 13. Rudarakanchana N, Berland TL, Chasin C, et al. Arteriovenous fistula after endovenous ablation for varicose veins. J Vasc Surg 2012; 55: 1492–1494. 14. Martin EC and Todd GJ. Embolization of an arteriovenous fistula after radiofrequency ablation (RFA) of the saphenous vein. Cardiovasc Intervent Radiol 2010; 33: 227–228.
Downloaded from vas.sagepub.com by guest on July 27, 2015
