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 34-year-old male patient had been treated by HD in the last 3 years via left brachiocephalic AVF. He presented with gradually increasing painful swelling of the left upper limb, a sign of VH. He was evaluated with CT angiography and documented to have stenosis at IJV and left brachiocephalic vein. Under local anesthesia, the right common femoral artery access was secured with a 5 French sheath. Using 5 French H1 catheter and hydrophilic guide wire, left brachial artery angiogram was performed. The left common femoral venous access secured. However, H1 catheter could not be negotiated into left brachiocephalic vein (the angiogram also confirmed the presence of an occlusion in left brachiocephalic vein. Echelon – 10 and traxcess for guide wire was placed within the venous side of AVF. A 6 × 20 microplex 18 coil was placed in the venous side. Subsequently 5 × 15 (GDC – 18) and 4 × 10 (GDC – 10) coils were placed within the venous side of a fistula, followed by introduction of fibrin glue, 1 ml (1:2 dilution). Final check angiogram revealed closure of AVF. Right lower limb was immobilized for 6 h and left upper limb raised. Limb edema disappeared in 48 h [].