An 85-year-old man presented with a 2-day history of intermittent, pressure-like substernal chest pain. His medical history included hypertension, hyperlipidemia, and recurrent deep vein thrombosis and pulmonary embolism. He had also undergone radiation treatment for prostate cancer and a prostatectomy. The patient's initial levels of cardiac troponin I were normal. An electrocardiogram showed nonspecific T-wave inversions in the anteroseptal leads. A nuclear stress test revealed a small inferoapical and septal-wall infarction with a small area of anterolateral wall ischemia. The patient underwent transradial cardiac catheterization and successful percutaneous coronary intervention in the proximal-to-mid left anterior descending coronary artery, and he was discharged from the hospital in good condition.
Approximately 2 months later, the patient reported having dyspnea on moderate exertion (New York Heart Association functional class II) and pain in his right wrist and thumb. A thrill was noted at the right radial puncture site. A duplex ultrasound arterial study of his right upper extremity revealed an arteriovenous fistula (AVF) at the wrist, involving the radial artery and the cephalic venous system (Fig. 1), with torrential flow characteristic of the major pressure difference between the artery and vein. The patient underwent ultrasound-guided surgical ablation of the AVF without complications, and his symptoms subsequently resolved.
When the transradial and transfemoral approaches for coronary intervention have been compared, the transradial approach has consistently been associated with shorter hospital stays and lower costs, fewer complications, and better patient satisfaction. In the Radial Versus Femoral Access for Coronary Angiography and Intervention (RIVAL) trial,1 investigators studied the results of these 2 interventions for acute coronary syndrome in 7,021 patients. They found iatrogenic AVF in 5 of 3,514 patients in the transfemoral group and in none of 3,507 patients in the transradial group.
An AVF can form during arterial access when a needle deviating through a venous tributary results in persistent communication between the artery and vein.2 The recommended treatment options are surgical repair, endovascular implantation of a covered stent, ultrasound-guided compression, and conservative therapy.2,3 As in our patient, surgical repair is indicated when an AVF is large, painful or compressive, or associated with high cardiac output.
Section editor: Raymond F. Stainback, MD