Abstract
Atrial septal device occluders such as amplatzer occluder have been designed to close atrial septal defects of paten formal ovale. Off label use of this device has been reported in pathological conditions that connect two vascular compartments with narrow neck. In this report, we describe a successful closure of a traumatically occurred AV fistula between iliac artery and iliac vein using amplatzer occluder device that has not been reported previously. This rare case is followed by a review of the literature.
Highlights
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Atrial septal device occluders such as amplatzer occluder (AO) has been designed to close atrial septal defects of pfos
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Off label use of this device has been successful in closure of two vascular compartments connected with narrow neck.
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Closure of a traumatically occurred AV fistula using AO between iliac artery and vein led to resolution of heart failure
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Case report
A 53-year-old female with history of progressive dyspnea admitted to emergency department with fever, cold swearing, chest discomfort, massive pink frothy sputum, loss of consciousness and respiratory distress due to pulmonary edema requiring mechanical ventilation. Lab data were within normal range except for Hb: 9.8 mg/dl. Her chest X ray revealed pulmonary edema. Her transthoracic echocardiogram revealed hyper dynamic left ventricular function initially thought to be related to chronic anemia. Left ventricle was mildly enlarged with mild pericardial effusion, moderate mitral regurgitation, moderate tricuspid regurgitation with estimated systolic pulmonary arterial pressure of 55 mmHg and mildly dilated inferior vena cava without normal respiratory collapse. Bubble study performed during her echocardiographic examination revealed presence of a small patent formal ovale (PFO).
Her past medical history was significant for thalassemia minor, hypothyroidism on levothyroxine and previous surgery for back complicated with blood lost and prolonged hospitalization 8 years ago. She was treated with warfarin due the pulmonary embolization occurring during her hospitalization after her surgery. Three years after her discharge, she developed gradual worsening of dyspnea without chest pain. She was admitted with progressive dyspnea and bloody stringed sputum many times in the last 6 years without any definite diagnosis. Pulmonary function test, coronary CT angiography and spiral CT were all unremarkable. Right heart catheterization was performed demonstrated pulmonary hypertension with a systolic pulmonary arterial pressure of 70 mmHg. This finding was attributed to chronic anemia due to her history of thalassemia minor and the patients was treated with busentan, sildenafil, Lasix, losartan, carvedilol and digoxin for two years. Meanwhile, she experienced one syncopal episode leading to electrophysiological study showing infra hessian block treated with dual chamber pacemaker insertion. Despite all these treatments, her clinical condition worsened and she was admitted with progressive dyspnea and flush pulmonary edema as described above.
On her physical examination, a continuous murmur and thrill at the right lower abdominal quadrant was noticed. She underwent abdominal CT angiography revealing the presence of a large fistula connecting right common iliac artery to iliac vein. The decision was made to proceed for fistula closure using amplatzer occluder device. The fistula was thought to be responsible for her high output left ventricular congestive heart failure with secondary pulmonary hypertension. The cause of fistula appeared to be related to her complicated disk surgery 8 years ago ( Fig. 1 ).
