A 53-year-old lady in established renal failure secondary to Alport's syndrome had been on haemodialysis for 6 years using a left brachio-cephalic AVF. Medications included dual anti-platelet therapy and a once daily dose of low-molecular-weight heparin. A right femoral dialysis catheter was inserted for haemodialysis at a district hospital where she presented with florid pulmonary oedema, rather than using the AVF for reasons that remain unclear. The procedure was apparently traumatic and painful with considerable bleeding upon removal of the catheter 2 weeks later.\nSubsequently she developed cardiac failure and was referred to cardiology for management of what was thought to be cardiac insufficiency. A transthoracic echocardiogram revealed moderate mitral stenosis and regurgitation with a hyperdynamic left ventricular function. Acute coronary syndrome was suspected, and cardiac catheterization performed through the same groin. The coronary angiographic study revealed moderate non-occlusive right coronary artery atherosclerosis. However, a femoro–femoral AVF was discovered (Figure ). It was postulated that the high output state was made worse by the iatrogenic femoral AVF.\nClinical assessment following referral for surgery revealed a palpable thrill and an audible bruit on auscultation in the affected groin. Surgical exploration revealed a communication between the superficial femoral artery (SFA) and the superficial femoral vein (SFV) (Figure ). The SFA and SFV were gently separated after full arterial and venous control, and a primary closure of both defects in the artery and vein was then carried out with running non-absorbable sutures (Figure ). The post-operative period was uneventful, and the patient discharged 2 days later.
A 63-year-old male patient had been treated by HD in the last 5 years via left brachiobasilic AVF. He presented with gradually increasing painful swelling of the left upper limb, a sign of VH. CT angiography documented left brachiobasilic vein stenosis with extensive collaterals in the upper limb. Under local anesthesia, the right common femoral artery access was obtained with 8 french arterial sheath. This was followed by 5 french micro venous sheaths in left basilic vein, distal to stenosis site via left common femoral venous access. Then a Swan-Ganz catheter was placed in the left brachial artery just proximal to fistula site, followed by inflation of the balloon, check angiogram showed patent fistula site with stenosis of basilic vein. Through dilator of 5 French sheath – 6, 8 cm × 5 cm pushable coils were placed in venous side just distal to fistula, followed by introduction of fibrin glue, 1 ml (1:2). Final check angiogram documented successful embolization. Also, in this case, a rapid disappearance of the edema occurred with a progressive resolution of the elephantiasis [].