Case report:
A 49-year-old male presented with complaints of mild swelling over the
radial aspect of the right distal forearm for the last 2 months with new
onset of mild pain in fingertips mainly thumb and index finger for a
week (Figure 1A). He had a history of percutaneous transluminal coronary
angioplasty (PTCA) 3 months back via the trans-radial route. The
swelling started 1 month after the procedure. On examination superficial
veins over distal forearm were prominent with thrill was palpable over
swelling. Mild prolonged capillary filling time noted mainly of thumb
and index fingers with no temperature change, suggestive of early
ischemic changes.
Ultrasound followed by computed angiography (CT) angiography was
performed for evaluation. CT revealed the complete occlusion of the
radial artery from its origin till the distal forearm. The ulnar artery
was normal and mild prominent. The radial artery at the wrist and
proximal hand was reformed by retrograde flow from the deep palmar arch.
This distal radial artery retrogradely supplying the arteriovenous
fistula (AVF) at distal forearm (Figure 2A,2B).
Initially, local compression under ultrasound guidance was attempted but
not successful. Since the artery was retrogradely filling from palmar
arch transarterial embolization and covered stent placement was
technically not feasible. Hence surgical ligation of arteriovenous
fistula under supraclavicular block was performed (Figure 1B). The
proximal and distal right radial artery, cephalic vein, and fistulous
connection were identified and the quadruple ligation of the AVF was
done. Postoperative recovery was uneventful, and the patient was
discharged on the first postoperative day.