Percutaneous glue embolization of arteriovenous fistula of in situ saphenous vein bypass graft: Case report and literature review

Objectives

In 1959, Charles Rob described a femoral-popliteal bypass graft in which the saphenous vein was left in place rather than reversed. In his procedure, the competency of the valves was compromised using an internal vein stripper and the vein branches were ligated to prevent the subsequent adverse effects of arteriovenous fistulas (AVFs). However, Rob did not develop an in situ procedure because he thought the procedure would be too time-consuming and that the risk of creating an AVF outweighed the possible advantages of the technique.

The development of Mills and Lemaitre valvulotomes resolved the valve lysis problem associated with Rob’s technique, but the problem of side branch ligation remained, accompanied by long skin incisions and the associated pain, infection, and poor wound healing.^1,2 Further AVF management, the so-called endovascular assistance, using a low-profile catheter and stainless-steel coils, made it possible to identify, select, and coil the side branches or retained fistulas during or after in situ bypass grafting.

Due to our previous experience with ultrasound-guided superficial vein occlusion and percutaneous arterial pseudoaneurysm embolization, we considered treating a case of late AVF in an in situ lower limb vein bypass by performing direct percutaneous glue injection. To our knowledge, there are no published cases describing this procedure. In this case report, we therefore describe our experience with percutaneous symptomatic AVF occlusion by cyanoacrylate injection according to the CARE (CAse REports) checklist for clinical cases. The main purpose of this article is to show an alternative treatment strategy to surgical ligation or coil embolization for symptomatic AVFs in a patient with an in situ peripheral vein bypass graft.

Methods

A 63-year-old diabetic male patient underwent a superficial femoral endarterectomy and an in situ below-the-knee bypass graft of the great saphenous vein as treatment for critical limb-threatening ischemia 4 years prior to this case study. The patient failed our ultrasound follow-up and returned to our attention after a recurrence of critical limb-threatening ischemia in the form of a first toe ulcer. In this case, the patient presented with an ankle pressure of 60 mmHg at the anterior tibial artery and an ankle/brachial index of 0.45. He was evaluated on an outpatient basis. Ultrasound and echo color Doppler revealed the characteristic patterns of an AVF: first, visualization of the collateral venous branch showed characteristic changes in color flow mapping, such as blooming and aliasing artifacts, and second, Doppler sampling demonstrated high systolic and diastolic blood flow velocities and spectral broadening, making it possible to confidently diagnose the AVF. The diagnosis of significant (>70%) lower limb bypass graft stenosis and a proximal AVF connected with the deep venous system was confirmed with CTA (Figure 1). There was no clinical evidence of edema or skin redness, suggesting that the AVF was chronic and late.OPEN IN VIEWER

We treated the patient by performing percutaneous angioplasty of the stenosis and contemporary AVF occlusion using ultrasound-guided glue injection. After administering 2% lidocaine, we pricked the origin of the femoral-popliteal venous bypass graft and inserted a short 4F introducer using the Seldinger technique. Initial angiography results indicated the presence of a tandem stenosis located just below the origin of the AVF. We performed progressive angioplasties of the stenosis with both 3 × 120 mm and 4 × 120 mm balloons, and then, we treated the stenotic segment using a drug-eluting balloon (AcoArt Litos 4 × 150 mm). The AVF was directly punctured using an ultrasound-guided 17-G metallic needle that had been previously flushed with 5% dextrose solution and was connected to a repository of 0.2 mL Glubran 2 (Figure 2). Glue was injected while the drug-eluting balloon was inflated to reduce the risk of embolization. Final angiography showed bypass graft patency and resolution of the stenosis without AVF persistence. The patient’s post-procedural medical history was uneventful: ultrasound evaluation showed complete AVF thrombosis (Figure 3), with a significant increase in dorsal foot perfusion (ABI 0.80) and no residual pain in the glue injection site.OPEN IN VIEWER

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Figure 3.

Ultrasound examination on the day following the procedure shows complete obliteration of the arteriovenous fistula.

Results

The potential problems of side vein branches and AVF development have been known from the first description of the in situ saphenous vein bypass technique. Surgical ligatures are associated with wound complication rates of up to 44%. ³ However, the likelihood of wound complications can be reduced by identifying side vein branches using ultrasound, angiography, or angioscopy during the vein bypass grafting procedure and then selectively ligating the side branches through a series of small incisions. ⁴ Although these incisions are significantly shorter, they do still carry a significant risk of skin necrosis (13%).

The development of endovascular techniques made it possible to perform catheter-guided cannulation of select side branches followed by coil embolization. This intraoperative approach during in situ vein grafting is called “closed” or “endovascular-assisted” in situ vein bypass grafting. A major principle of this “closed” grafting procedure is cannulating and coiling only the side branches that are greater than 2 mm in diameter, connected with the deep vein system, and have the potential to affect bypass hemodynamics. ³ Applying these selective criteria for AVF embolization reduces both the operating time and the risk of vein damage associated with prolonged endovascular cannulation maneuvers for smaller AVFs. ⁵ For the same reason, embolization is not appropriate in smaller bypass veins (<2.5–3.0 mm in diameter) because the use of aggressive endovascular instrumentation may cause intimal trauma and associated early graft failure. ⁶

Another potential risk of endovascular AVF embolization is inadvertent graft embolization. For this reason, some authors suggest performing embolization before completing the distal anastomosis. ⁷ Ultrasound-guided cyanoacrylate embolization has been widely used for the treatment of varicose veins and arterial pseudoaneurysms.^8,9 This synthetically derived glue polymerizes within 1–5 s and therefore reduces the risk of graft embolization. For example, when pure Glubran 2 is injected into a vessel in which blood flow is interrupted, polymerization occurs in a few seconds, thus avoiding the risk of graft embolization. Concurrent inflation of the ingraft balloon additionally prevents both arterial and deep vein embolization, as described for femoral pseudoaneurysm closure. ¹⁰

Based on the single case experience we report here, we believe AVF closure via direct glue injection a useful tool which can be faster for intraoperative use during “closed” in situ vein grafting and cheaper than coil embolization. We suggest that glue-based AVF closure is particularly indicated for cases of bypass veins where endovascular embolization could be harmful due to potential endothelial injury.

Conclusions

In this case study, it is possible that the patient developed an AVF following multiple stenoses along the course of his vein bypass graft. Arteriovenous fistula embolization with Glubran 2 concomitant with graft angioplasty could be an alternative AVF treatment strategy that avoids the need for major surgical ligatures.