Recently, catheter-directed local thrombolysis hasbeen widely accepted as an effective method to treatacute deep vein thrombosis of the lower extremities (1-3). Vascular access through the popliteal vein is the mostcommon route for the procedure. To date, procedure-re-lated complications such as hemorrhaging, pulmonaryembolism, infection and, sepsis have been reported.However, to our knowledge, iatrogenic arteriovenousfistulas have not been reported to date (4).

We experienced a case of an arteriovenous fistula be-tween the sural artery and popliteal vein and report it asone of the potential complications after endovascularthrombolytic therapy of acute deep vein thrombosis.

Case Report

A 52-year-old woman presented with bilateral lowerextremity varicose veins. A Doppler ultrasonography re-vealed reflux in the great saphenous and perforatingveins of the calves, which is an indicator of venous in-sufficiency. In addition, no deep vein thrombosis wasobserved. Ligation and electrocauterization of the greatsaphenous and perforating veins was performed undergeneral anesthesia with no immediate postoperativecomplications.

Five days after surgery, the patient experienced painin the left thigh and edema of the lower extremities, in-dicating a suspecgted case of deep vein thrombosis. ADoppler ultrasonography found that the left commonfemoral, superficial femoral, and popliteal veins werenot compressed. It also revealed that the lumen was ex-panded and filled with thrombus, which led to the diag-nosis of deep vein thrombosis. A CT angiography wasperformed to identify the extent of the thrombus. Thevenous phase revealed low density thrombi of the com-mon iliac and external iliac veins, as well as a floating

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Arterivenous Fistula Complicated by Popliteal VenousAccess for Endovascular Thrombolytic Therapy of

Deep Vein Thrombosis1

Sung Su Byun, M.D.2, Jeong Ho Kim, M.D.2, Chul Hi Park, M.D.2, Young Sun Jeon, M.D., Hee Young Hwang, M.D.2, Hyung Sik Kim, M.D.2, Won Hong Kim, M.D.

1Department of Radiology, Inha University College of Medicine, Korea2Department of Radiology, Gacheon University Gil Medical Center, KoreaReceived June 27, 2008 ; Accepted August 18, 2008Address reprint requests to : Jeong Ho Kim, M.D., Department ofRadiology, Gacheon University Gil Medical Center, 1198, Guwol-dong,Namdong-gu, Inchon 405-760, KoreaTel. 82-32-460-3063 Fax. 82-32-460-3065 E-mail: k7ok7@gilhospital.com

We report a case of an iatrogenic arteriovenous fistula complicated by catheter-di-rected thrombolytic therapy in a patient with acute deep vein thrombosis of a lowerextremity. To the best of our knowledge, this is the first report of an arteriovenous fis-tula between the sural artery and popliteal vein in that situation. As the vessels have aclose anatomical relationship, the arteriovenous fistula seems to be a potential compli-cation after endovascular thrombolytic therapy of acute deep vein thrombosis.

Index words : Venous thrombosisArteriovenous fistula Popliteal veinCatheterization

thrombus in the infrarenal inferior vena cava.Consequently, a retrievable filter (Optease retrievablevena cava filter, Cordis, Miami, U.S.A.) was inserted.The catheter-directed local thrombolysis was scheduledfor the treatment of deep vein thrombosis. After p;acingthe patient in the prone position, the popliteal regionwas prepared. Next, the posterior wall of the poplitealvein was punctured with a 21G microneedle(Micropuncture introducer set, Cook, Bloomington,U.S.A.) using a 0.018-inch guidewire (Micropuncture in-troducer set, Cook, Bloomington, U.S.A.), to avoid punc-turing the popliteal artery. After a 6-F sidearm sheath(Radiofocus, Terumo Corporation, Tokyo, Japan) wasinserted, an 11 cm infusion catheter (multi-sideportcatheter infusion set, Cook, Bloomington, U.S.A.) waspositioned in the thrombus and 1.6 million IU of uroki-nase was administered at a rate of 100,000 IU/hour. Anascending venography performed 16 hours later showedan almost complete eradication of the left superficialfemoral and popliteal veins. However, thrombus wasstill present in the left external iliac vein. Moreover, theleft common iliac vein was strictured, causing insuffi-cient circulation. The sheath was exchanged for a 10-Flong sheath, followed by performing an aspirationthrombectomy, a procedure in which the thrombus iseradicated by using negative pressure created by a 50 ccsyringe, was performed after inserting a 8-F Hoffmansheath (Cook, Bloomington, U.S.A.).

An angioplasty was performed by inserting a 14 mm×8 cm metallic stent (Wallstent Endoprosthesis, BostonScientific, Galway, Ireland) in the left common iliac veinusing a 14 mm×2 cm balloon catheter (ATB advance,Cook, Bloomington, U.S.A.), and an inflator (Inflator,Guidant, Indianapolis, U.S.A). A follow-up ascendingvenography revealed a complete eradication of thethrombus and no problems with circulation. As a resultthe procedure was terminated.

The patient was discharged without any symptoms,but thrills were palpated in follow-up examinations. Inthe arterial phase of a follow-up CT angiography, the leftpopliteal, femoral, and iliac veins appeared to have thesame density as the arteries, thus suggesting the devel-opment of an arteriovenous fistula (Fig. 1). A Dopplerultrasonography revealed intravenous arterial bloodflow superior to the popliteal vein; however, a definitefistular tract could not be found. The CT angiographicimages obtained before and after surgery were com-pared retrospectively. A sural artery was found to bewrapped externally around the popliteal vein (Fig. 2A).

The postoperative images showed that the left suralartery had thickened, which was substantiated by thefact that contrast fluid was leaking into the poplitealvein. As a result, we concluded that the arteriovenousfistula had occurred between the sural artery andpopliteal vein (Fig. 2B). A procedure was performed totreat the arteriovenous fistula. When the popliteal veinwas exposed, a small artery was connected to thepopliteal vein in the posterolateral direction of thepopliteal vein. This was judged to be the arteriovenousfistula and was subsequently ligated. A Doppler unltra-sonography performed in the operative field showed noarterial wave forms in the veins and the thrills were nolonger palpated. The patient was discharged followingthe operation and has had no arteriovenous fistula re-currence.

Discussion

In treating acute deep vein thrombosis of the lower ex-tremities, we found that a catheter-directed local throm-bolysis rapidly eliminates more thrombus than currentconventional treatments including leg elevation, wear-ing an elastic stocking, conventional anticoagulation,and whole body thrombolysis. Catheter-directed localthrombolysis also allows the patient’s circulation to re-cover. In addition, it eliminates the pain and edema aswell as maintains the valvular function of the veinswhich could prevent post-thrombotic syndrome.Performing a catheter-directed local thrombolysis canalso normalize local stenosis and obstruction by insert-

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Fig. 1. An axial image of the contrast-enhanced CT angiogra-phy in the arterial phase showed strong enhancement of leftcommon femoral vein (arrow). This was consistent with thearteriovenous fistula and was comparable with the contralater-al common femoral vein.

ing a stent. Therefore, it is recognized as the most effec-tive treatment (1-3).

The access route differs according to the extent and lo-cation of the thrombus; however, the ipsilateralpopliteal vein of the lesion is most commonly used. Thisis because the lesions are easily approached via the guid-ance of US and the instruments can easily pass throughthe direction of the valve, which makes thrombolysis,angioplasty, and the insertion of stents possible. This isespecially useful in patients with iliofemoral veinthrombosis (1, 2).

The most common complication of this procedure isbleeding. Local bleeding in the region of access andbleeding in remote regions such as the intracranium,retroperitoneum, gastrointestinal system, musculoskele-tal system, and genitourinary system have been report-ed. Bleeding that requires transfusion occurred in ap-proximately 5-10% of cases and primarily occurs at thepuncture site (1, 2). Minor bleeding that doesn’t requirespecial treatment has been reported in 16% of cases andintracranial bleeding occurred in 0.2-0.4% (1-3).

Bjarnason et al. (5) reported that the rate of pulmonaryembolisms was 1%; however, according to The NationalVenous Registry (6), fatal pulmonary embolisms oc-curred in only one patient out of 422. Further, it isknown that death due to catheter-directed local throm-bolysis is rare. Other complications related to the proce-dure include infection and sepsis (1, 2).

There are no known reported cases for the develop-ment of an arteriovenous fistula following catheter-di-rected thrombolysis in the popliteal fossa as in this cur-rent case study. In a study on the anatomical relations ofthe popliteal artery and vein by Trigaux et al. (7), thepopliteal artery was located anterior to the popliteal veinin 92% of cases, Moreover, more than 25% of the diam-eter of the popliteal artery was overlapped by thepopliteal vein in 87% of cases. Further, the authors doc-umented that when the popliteal artery was puncturedpercutaneously from the posterior, the needle passes thepopliteal vein, and caution is required because there is apossibility for the formation of an arteriovenous fistula.However, unlike the iatrogenic arteriovenous fistula

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A

Fig. 2. Axial images of contrast-en-hanced CT angiography in the arterialphase before (A) and after (B) a retro-spective review of endovascularthrombolytic therapy of acute deepvein thrombosis. For this patient, thesural arteries (white arrows) arosefrom the popliteal arteries and ranwrapping around the popliteal veins(black arrows) posterolaterally.Following treatment, the left suralartery revealed a greater degree of di-lation. In addition, contrast leakagefrom the left sural artery into leftpopliteal vein was noted.

B

that occurs in 1-5% after intervention through thefemoral artery, complications are relatively rare in thepopliteal fossa (4, 8). This is probably because iatrogenicarteriovenous fistulas rarely occur when only the poste-rior wall of the popliteal vein is punctured for catheter-directed thrombolysis, while the patient is put into aprone position due to the anatomical relations of thepopliteal artery and vein. Also, the intervention throughthe popliteal artery or vein was performed less frequent-ly than the intervention through the femoral artery orvein and was not as aggressive, contributing to relativelyless development of complications. However, as thecatheter-directed local thrombolysis is standardized asthe treatment of deep vein thrombosis in the lower ex-tremities, more procedures are expected to be per-formed. As a result, the sural artery, which is a smallbranch of the popliteal artery, can potentially be a haz-ard to develop into an arteriovenous fistula. Thus, morestudies are required to assess the anatomical relation-ship between the anatomical relations of the sural arteryand popliteal vein.

The sural artery branches, from the popliteal artery in-to the medial and lateral branch at the level of the kneejoint, supply the gastrocnemius, soleus, and plantarismuscles and have branches of various sizes that run par-allel to the small saphenous vein and supplies the super-ficial tissues (9). Timperman et al. (10) reported the oc-currence of an arteriovenous fistula between the super-ficial sural artery and small saphenous vein after intra-venous laser treatment in patients with lower extremityvaricose veins due to the insufficiency of the smallsaphenous vein. They assumed this as a possible com-plication based on the fact that the superficial suralartery is located medially and posteriorly to the smallsaphenous vein, and that they run together in 91% ofcases. As well, they insisted that the development of afistula should be evaluated after the procedure by colorultrasonography. In this case, the CT angiographyshowed that the lateral sural artery branched from thepopliteal artery, passed the popliteal vein, and wrappeditself around it. This kind of anatomical relationship isthought to be the cause of an arteriovenous fistula.

The sural artery in the popliteal fossa is so small that it

cannot be easily detected on gray scale ultrasonography.In our opinion, careful color-coded duplex ultrasonogra-phy with positioning of the color box aroundsaphenopopliteal junction, popliteal vein, and smallsaphenous vein, could help find the sural artery in thepopliteal fossa.

In conclusion, we reported a case of an arteriovenousfistula in the popliteal fossa, between the popliteal veinand sural artery, after a catheter-directed local throm-bolysis. The anatomical relations of the sural artery andpopliteal vein should be considered when the poplitealvein is punctured under US guidance. Also, the possibil-ity of an arteriovenous fistula should be recognized andproper management should be taken.

References

1. Sharafuddin MJ, Sun S, Hoballah JJ, Youness FM, Sharp WJ, RohBS. Endovascular management of venous thrombotic ans occlu-sive disease of the lower extremities. J Vasc Interv Radiol2003;14:405-423

2. Semba CP, Razavi MK, Kee ST, Sze DY, Dake MD. Thrombolysisfor lower extremity deep venous thrombosis. Tech Vasc IntervRadiol 2004;7:68-78

3. Comerota AJ, Paolini D. Treatment of acute iliofemoral deep ve-nous thrombosis: a strategy of thrombus removal. Eur J VascEndovasc Surg 2007;33:351-360

4. Yilmaz S, Sindel T, Luleci E. Ultrasound-guided retrogradepopliteal artery catheterization: experience in 174 consecutive pa-tients. J Endovasc Ther 2005;12:714-722

5. Bjarnason H, Kruse JR, Asinger DA, Nazarian GK, Dietz Jr CA,Caldwell MD, et al. Iliofemoral deep venous thrombosis: safetyand efficacy outcome during 5 years of catheter-directed throm-bolytic therapy. J Vasc Interv Radiol 1997;8:405-418

6. Mewissen MW, Seabrook GR, Meissner MH, Cynamon J,Labropoulos N, Haughton SH. Catheter-directed thrombolysis forlower extremity deep venous thrombosis: report of a national mul-ti-center registry. Radiology 1999;211:39-49

7. Trigaux JP, Van Beers B, De Wispelaere JF. Anatomic relationshipbetween the popliteal artery and vein: a guide to accurate angio-graphic puncture. AJR Am J Roentgenol 1991;157:1259-1262

8. Seay T, Soares G, Dawson D. Postcatheterization arteriovenous fis-tula : CT, ultrasound, and arteriographic findings. Emerg Radiol2002;9(5):296-299

9. Colborn GL, Lumsden AB, Taylor BS, Skandalakis JE. The sugricalanatomy of the popliteal artery. Am J Surg 1994;60:238-246

10. Timperman PE. Arteriovenous fistula after endovenous laser treat-ment of the short saphenous vein. J Vasc Interv Radiol 2004;15:625-627

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대한영상의학회지 2008;59:235-239

심부정맥혈전증 환자에서 혈전용해술을 위한오금정맥 천자 후 발생한 동정맥루1

1인하대학교 의과대학 영상의학교실2가천의과학대학교 의학전문대학원 영상의학교실

변성수2·김정호2·박철희2·전용선·황희영2·김형식2·김원홍

저자들은 하지의 급성 심부정맥혈전증 환자에서 카테터를 이용한 혈전용해술을 시행한 후 발생한 의인성 동정맥

루 1예를 보고하고자 한다. 동정맥루는 오금동맥의 곁가지인 장딴지동맥과 오금정맥 사이에 발생하였으며 이는 지

금까지 문헌에 보고된 바가 없다. 장딴지동맥과 오금정맥은 해부학적으로 밀접한 관계가 있으므로 두 혈관 사이의

동정맥루는 혈전용해술 후에 발생할 수 있는 잠재적인 합병증의 하나로 생각된다.