Complex Complications Following Unguided Femoral Catheterization

A 29-year-old male on dialysis presented with progressive right lower limb swelling and bluish discoloration for the last 18 months. He had undergone non-imaging-guided right femoral catheterization 2 years back. Examination revealed bruit at the right thigh. Doppler followed by CT angiography examination confirmed an arteriovenous fistula (AVF) between the right superficial femoral artery (SFA) and common femoral vein (CFV) [Figure 1a-d], with SFA pseudoaneurysm (PSA) [Figure 1e-h], and CFA stenosis [Figure 1l-m]. Management with covered stent placement and percutaneous angioplasty was offered. However, the patient refused treatment and was lost to follow-up. AVF has an ∼0.86% incidence as a complication of femoral catheterization.¹ PSA and venous stenosis, however, are common complications.² Our patients had 2/3: expanding pulsatile mass, bruit over the femoral artery, and on-site tenderness.^1-3 Symptoms arise within days to months after catheter removal, but can be delayed up-till 6 months.⁴ Risk factors include the use of a large catheter, distal femoral puncture, and a non-guided procedure.^2-4 Venous stenosis is more frequent with long duration and repeated catheterization.⁵ It is significant if the peak velocity ratio is >2.5 times across the stenosis or there is >50% luminal diameter narrowing.⁵ Endovascular covered stent placement is the go-to method, and those not suitable are considered for surgery.^2,3 Symptomatic venous stenosis is treated with percutaneous angioplasty.⁵ This case illustrates the risk of complications in non-imaging-guided catheterization and the need to always perform a holistic evaluation. It depicts that AVF and PSA can be delayed complications of catheterizations.

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Figure 1:

(a) Grey scale ultrasonographic (USG) image showing abnormal communication (yellow arrow) between superficial femoral artery (SFA) and common femoral vein (CFV) along with enlarged great saphenous vein (GSV) and its dilated tributary. (b) Color doppler findings showing aliasing at the site of fistula. (c) CT angiography MPR image showing abnormal communication (yellow arrow) between the CFV and SFA with early opacification of the CFV. (d) Pulsed doppler findings representing high velocity (153 m/s) arterialized flow in the CFV. F/s/o Arteriovenous fistula between SFA and CFV. (e) Grey scale Ultrasonographic (USG) image showing blind ending pouch arising from the anterio-medial wall of the proximal superficial femoral artery (SFA), with corresponding color doppler (f) showing ying-yang sign and pulsed doppler (g) showing “to-and-fro” pattern. (h) MIP reconstructed CT angiographic image showing blind ending pouch arising from SFA- /s/o SFA pseudoaneurysm. (i) Grey scale USG image showing stenosis in right CFV for a length of 1.8 cm, with diameter of pre-stenotic (yellow arowhead), stenotic (yellow arrow) and post-stenotic (yellow blocked arrow) segment being, 8 mm, 4.3 mm and 14 mm, with corresponding color doppler and pulsed doppler images. (j-k) showing increased turbulent flow at the site of stenosis (J) (132 cm/s) with flow in the distal dilated segment (43 cm/s). (l-m) Volume rendering technique (VRT) reconstructed image and MIP reconstructed image in sagittal plane depicting stenosis (yellow arrowheads) in CFV, with multiple collateral venous channels (yellow arrows) redirecting venous return directly to right external iliac vein. F/s/o CFV stenosis with collateral development.

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