A 49-year-old man underwent catheter ablation for drug-refractory atrial fibrillation using right femoral access. A 3-French sheath was placed in the right CFA, and an 8-French sheath was placed in the right FV during the catheterization. After the procedure, he developed swelling around the puncture site, and a bruit was audible in the right groin on auscultation. An AVF was detected by color Doppler ultrasound (Figure ). Ultrasound-guided compression was attempted but was unsuccessful. Enhanced computed tomography (CT) showed an MCFA originating from the CFA that crossed anterior to the FV and an arteriovenous communication (Figure ).\nExpecting spontaneous resolution, the patient was initially treated conservatively. After six months of follow-up, the AVF did not disappear on ultrasonography, and he suffered recurrence of atrial fibrillation. Considering the risk of future cardiac complications due to sustained volume overload, surgical intervention was performed. Surgical exploration revealed a dilated MCFA that crossed anterior to the FV (Figure ).\nThe MCFA was attached to the FV, and thrill was present. Ligation of the AVF was performed. A completion angiogram demonstrated successful closure of the AVF (Figure ).\nThe postoperative course was uneventful, and the patient was discharged on postoperative day 4.
A 64-year-old male patient had been treated by HD in the last 5 years via right brachiocephalic fistula (BCF). He presented with gradually increasing painful swelling of the right upper limb, a sign of VH. He was evaluated with CT angiography and documented to have right internal jugular vein (IJV) stenosis with extensive collaterals in upper limb [].\nUnder all aseptic precautions, right IJV access was secured with 7 Fr sheaths. 5 Fr KMP catheter was used to negotiate across the IJV stenosis over a guide wire. A 10 mm × 40 mm balloon dilator was deployed across the stenosis and dilatation done. 14 mm × 40 mm self-expandable stent was passed across the stenosis. Poststent check angiogram revealed few collaterals still persisting around the stenotic site []. The AVF was cannulated via radial artery and fistulogram done revealing multiple stenosis along the whole length of the cephalic vein which were dilated sequentially from central to the peripheral. The venogram revealed persistent stenosis in IJV proximal to the level of the stent already in situ. Another 14 mm × 40 mm self-expandable stent was deployed proximal to the first one and final check angiogram revealed good direct flow in central vein []. AE of the peripheral collaterals near the anastomotic site was also done to give a further advantage.