Repair of a high-flow superficial femoral arteriovenous fistula using a bell-bottom iliac limb endoprosthesis

Abstract

A 50-year-old patient had presented with recalcitrant right lower extremity venous stasis ulceration, atrial fibrillation, and congestive heart failure. He had a history of a gunshot wound to the right thigh >30 years previously, which had been managed without surgery. Computed tomography angiography indicated a fistulous communication between the right superficial femoral artery and vein with massively dilated right iliofemoral venous and arterial systems. He was treated with stent-graft coverage of the superficial femoral arteriovenous fistula using a bell-bottom iliac limb endoprosthesis. This stent-graft accommodated the diameter asymmetry in the superficial femoral artery caused by the long-standing fistula and ameliorated the symptoms that had afflicted him for decades.

Keywords: Arteriovenous fistula; Stent-graft; Superficial femoral artery.

Fig 1

Computed tomography angiogram demonstrating a large arteriovenous fistula (AVF) between the superficial femoral artery and femoral vein. The arrow indicates the fistulous connection. Note is made of dilated and tortuous superficial veins and ectatic arteries.

Fig 2

A, Intravascular ultrasound within the superficial femoral artery was used to delineate the fistulous connection and obtain the diameter measurements. B, Digital subtraction angiogram revealing a pseudoaneurysm in the right distal superficial femoral artery with fistula connection to the femoral vein. C, Post-stenting angiogram indicating exclusion of the arteriovenous fistula (AVF) and pseudoaneurysm. The arrow indicates the fistulous connection.

Fig 3

Three-dimensional computed tomography angiographic reconstructions before (A) and 18 months after (B) superficial femoral artery stent-graft placement. Centerline reconstructions before (C) and 18 months after (D) superficial femoral artery stent-graft placement. The arrow indicates the fistulous connection.