Endovascular management of multiple arteriovenous fistulae following failed laser-assisted pacemaker lead extraction

Abstract

A woman presented for evaluation of new-onset left arm edema after failed laser-assisted pacemaker lead extraction. Initial workup demonstrated a left subclavian artery to vein arteriovenous fistula (AVF). She underwent repair of the AVF with placement of a covered stent in the subclavian artery, however, her symptoms did not completely resolve. Investigation revealed a left common carotid artery to left innominate vein AVF, which was repaired by deploying a covered stent retrograde into the left common carotid artery. Her symptoms subsequently resolved. Multiple iatrogenic AVF can be repaired endovascularly, however, a high degree of suspicion for multiple injuries should be maintained.

Iatrogenic Subclavian Arteriovenous Fistula: Rare Complication of Plate Osteosynthesis of Clavicle Fracture

“…In our study, arteriovenous fi stula was treated by endovascular surgical techniques, which have been recommended by several authors. [10][11][12] With balloon-assisted selective occlusion of the subclavian artery, implant removal is much safer and prevents the possibility of massive hemorrhage. The use of endovascular stent grafts reduces the need for surgical dissection and the risk of injuring the surrounding structures, such as the vagus nerve, recurrent laryngeal nerve, phrenic nerve, and innominate vein.…”

Left common carotid artery to left innominate vein arteriovenous fistula after transvenous laser lead extraction

“…Most published cases reported innominate, left internal mammary or subclavian arteries involvement. Iatrogenic TLE‐associated AVF linking the LCCA to ipsilateral innominate vein have only been reported in five previous cases, all with an initial symptomatic presentation, as opposed to ours 3,11,15,18,21 …”

“…Although usually described during lead implantation, AVF have been reported after extraction using laser sheaths 1,3,4,11,15–19 . Favored by the anatomical proximity of the vascular structures and the fibrotic attachments binding the lead to the inner venous wall over time, AVF formation has previously been related to prolonged and challenging powered tool advancement 20 .…”

Iatrogenic left internal thoracic artery to left subclavian vein fistula after excimer laser pacemaker lead extraction

“…1 Since then, 6 other cases have been reported in the literature, including 2 from our institution. [2][3][4][5] Clinical presentations have included a combination of symptoms (acute-onset severe chest pain or progressive dyspnea and extremity edema), signs (hemodynamic instability, new murmur or thrill), and radiographic abnormalities (widened mediastinum, unilateral hemothorax, valvular dysfunction). Diagnosis has been confirmed with formal angiography.…”