Coil occlusion of a femoral arteriovenous fistula

A 17-mo-old, 9.9-kg child with an unbalanced atrioventricular septal defect, hypoplastic left ventricle, D-transposition of the great arteries, and pulmonary atresia was seen for elective cardiac catheterization to determine his suitability for a Fontan procedure. A modified Blalock-Taussig shunt had been performed when the infant was 5 days old, followed 8 mo later by a hemi-Fontan procedure. The patient was growing well and was mildly cyanotic with systemic arterial oxygen saturation of 88%. There were no other cardiovascular symptoms, including claudication or lower-extremity edema. On physical examination, a continuous bruit and prominent thrill were present in the right groin. The family and other medical care providers had not recognized the thrill previously. Diagnostic cardiac catheterization had been performed through the right femoral artery and vein when the infant was age 5 mo, before a hemi-Fontan procedure. No complications of catheterization had been noted, and the postoperative course was uneventful. Owing to the presumptive diagnosis of FAVF, catheterization was undertaken through the left femoral artery and vein as well as the right subclavian vein. Oximetry and angiography showed significant left-to-right shunting at the FAVF. Oxygen saturation levels were 63% in the superior vena cava, 77% in the inferior vena cava, 88% in the aorta, and 93% in the left atrium. Right ventricular volume overload was present, with a right ventricular end-diastolic volume index of 182 mL/m 2 . The patient was otherwise a good Fontan candidate. A 4F Judkins left coronary artery catheter with a 2.5-cm curve (Mallincrodt Medical, St. Louis, MO) was advanced from the left femoral artery to the aortic bifurcation. The tip of a 0.035-inch J-tipped guide wire (Argon Inc., Athens, Texas) was advanced through the catheter and directed at the right iliac artery. The coronary catheter was advanced over the wire until its tip engaged the mouth of the iliac artery. At this point the guide wire and then the catheter were advanced easily into the right femoral artery. Angiography showed FAVF with rapid runoff. Dense opacification of both femoral artery and vein substantially obscured the fistula itself. The Judkins left coronary artery catheter was exchanged for a 4F Judkins right coronary artery catheter to catheterize the FAVF selectively. Catheter entry into the FAVF was facilitated by placement of a metal clamp over the inguinal thrill for use as a fluoroscopic landmark , and with the aid of a 0.035-inch Glide wire (Medi-tech, Watertown, MA), the catheter was advanced through the FAVF into the right femoral vein. Injection of radiographic contrast into the right femoral vein during manual compression of the vein superior to the catheter tip resulted in retrograde filling of the fistula tract, clearly showing the size and course of the fistulous connection (Fig. 1). A single Gianturco coil (occluding spring embolus; Cook, Bloomington, IN) of 0.035-inch caliber, 4 cm in length, and a 3-mm helical diameter was chosen for occlusion of the FAVF. The coil delivery technique was similar to the technique used for coil embolization of the ductus arteriosus [2]. A single coil loop was placed on the venous