percutaneous transfemoral arterial catheterization is commonly preferred as the mode of access for a multitude of diagnostic and interventional procedures by cardiologists and interventional radiologists .
percutaneous femoral venous catheterization is often used by intensivists and nephrologists for temporary haemodialysis access .
puncture site complications can occur , most frequently haemorrhage , pseudoaneurysm formation , dissection with arterial thrombosis and distal thromboembolism .
femoral avfs can result from penetrating injuries as well as more frequently from percutaneous vascular interventions .
the incidence of post - catheterization avfs ranges from 0.006 to 0.86% whilst that of all vascular complications varies from 1 to 9% [ 14 ] .
avfs in the groin frequently result from low groin punctures . the lack of bony support during compression post - catheter removal results in difficulty in achieving haemostasis .
this is further compounded by the anatomical positions of the common femoral vein lying almost behind the superficial femoral artery .
we report a case of an iatrogenic avf resulting from placement of a temporary dialysis femoral line in the groin leading to worsening of cardiac failure .
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 .
subsequently 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 .
it was postulated that the high output state was made worse by the iatrogenic femoral avf .
angiography revealing the arteriovenous communication ( between the superficial femoral artery and superficial femoral vein ) .
clinical 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 2 ) .
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 3 ) .
the post - operative period was uneventful , and the patient discharged 2 days later .
intra - operative exposure of the fistulous connection ( artery is slung proximal and distal to the fistula ) .
avf represents an abnormal communication occurring secondary to penetrating injuries , rarely in blunt trauma   or as a result of percutaneous interventions , surgical procedures and venous catheterization of the extremities .
diagnosis can be achieved by history and clinical examination , and this can be complemented by imaging modalities such as colour - coded doppler ultrasound ( duplex ultrasonography ) , ct or mr imaging as well as conventional angiography for accurate localization of the avf   although duplex scan is the simplest and least invasive method .
surgical repair remains the gold standard in which the fistulous tract is identified , resected and primary repair performed .
potential complications of surgical intervention are major bleeding from venous hypertension of the arterialized vein , groin infection and cutaneous scarring .
other modalities of treatment that have been described mainly fall into the endovascular group and include covered stent , coil embolization and the utilization of glue . the close proximity of the fistula to the bifurcation of the common femoral artery precluded the use of these modalities in this instance .
watchful waiting and ultrasound - guided compression have been advocated as first line therapeutic options as they are both non - invasive . however , spontaneous closure is less likely to occur due to the fact that most patients are on anti - platelet and anti - coagulant therapy . post - catheterization femoral avfs are not immediately life threatening , but high output cardiac failure , chronic limb oedema and aneurysmal degeneration of the artery are documented consequences .
risks factors that increase the likelihood of developing avfs include distal groin punctures , arterial hypertension , female gender , peri - procedural anti - coagulation and anti - platelet therapy . in this instance , the puncture was low at the level of the sfa and vein . it is recommended that ultrasonography is used to direct needle puncture to avoid repeated blind punctures .
ultrasonography is known to reduce carotid arterial puncture when inserting dialysis catheters in the neck .
it is likely that ultrasonography may also assist in the placement of femoral vein catheters by clearly visualizing the common femoral vein as well as the artery and its branches .
 a patient presented with cardiac failure and investigations revealed a right femoral arteriovenous fistula ( avf ) 5 weeks after the insertion of a femoral dialysis catheter for haemodialysis . 
 no ultrasound had been used for catheter insertion . 
 the iatrogenic avf was repaired , and her episodes of cardiac failure ceased . 
 it is recommended that femoral dialysis catheters are inserted using ultrasound guidance to avoid inadvertent arterial puncture . 
Introduction
Case report
Discussion