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the transfemoral approach using the seldinger technique has been considered the preferred method for both coronary and peripheral arteriography .
local vascular complications of transfemoral arteriography , advocated by judkins,1 ) are rare ( 5% to 10% ) but potentially serious.2)3 ) a meta analysis found major access complications in 0.3% of cases that used the transfemoral approach ( p<0.0001).4 ) complications that require surgical correction are more common when the arterial puncture site is outside the common femoral artery .
the types of complications associated with the transfemoral approach were variable and included groin hematoma , arteriovenous fistula ( avf ) , false aneurysms , arterial dissection , arterial perforation and neurological deficits.5 ) transradial access for coronary artery intervention dramatically reduces these access site complications.1 ) only three cases of avf have been reported in previously published studies of radial catheter - based procedures ( table 1).6)7 ) we report here a rare case of avf , which developed after coronary angiography perfomed using the transradial approach .
a 67-year - old man visited our hospital with a palpable mass on his right wrist .
one year ago he underwent percutaneous coronary intervention ( pci ) for unstable angina , along with implantation of a drug - eluting stents in the proximal and distal right coronary artery and in the left anterior descending artery using the transradial approach without complication .
blood pressure was 109/62 mmhg , heart rate was 90 beats / minute , and there were no other abnormal findings after physical examination and biochemical tests .
an electrocardiogram showed t - wave inversion in leads ii and iii , and avf without interval change .
he complained of a palpable mass ( 31.5 cm ) on his right wristat the previous puncture site of the radial artery , where palpated thrill , auscultated bruit , and edema were observed .
a vascular ultrasound scan revealed suspicious turbulent flow in the systolic and diastolic phase at the previous puncture site of the right radial artery , which suggested avf or pseudoaneurysm ( fig .
1 ) . upper extremity computed tomography ( ct ) angiography revealed avf between the right radial artery and the adjacent cephalic vein around the right wrist .
2b , white arrows ) , and subclavian veins , and the superior vena cava ( fig .
2c , white arrows ) in the arterial phase through the fistula between the radial artery and the cephalic vein . the patient was referred to a vascular surgeon and received surgical ligation of the avf .
it may be congenital , surgically created for hemodialysis treatment , or pathologically acquired via trauma or erosion of an arterial aneurysm .
an avf results in a disruption of the normal blood flow pattern . normally , oxygenated blood flows to tissues through arteries and capillaries .
following the release of oxygen , the blood returns to the heart in veins . in case of avf , the blood bypasses the capillaries and tissues , returning directly to the heart .
arterial blood has a higher blood pressure than venous blood , and causes swelling of veins involved in the fistula .
percutaneous transfemoral arterial cardiac catheterization has reached widespread acceptance and achieved remarkable growth as a tool for diagnostic and therapeutic endovascular intervention . in the large scale prospective study of kent et al.8 ) which included 1,838 patients ,
the majority of patients who suffer from an iatrogenic avf do not develop clinical signs of hemodynamic significance .
all patients were routinely examined by the clinician before and after catheterization , including auscultation of both groins . in cases where there is clinical suspicion of a vascular complication , a duplex scan can be performed .
these are surgical repair , implantation of covered stents , and ultrasound guided compression.9 ) among them , surgical repair has frequently been recommended for patients with iatrogenic avf.9 ) the use of transradial access for pci has increased dramatically since the first report of transradial cardiac catheterization in 198910 ) and pci in 1993.11 ) the transradial approach is associated with fewer vascular access complications than the transfemoral approach.5 ) furthermore , an avf of the radial artery is rare , and even less common than radial artery pseudoaneurysm because only small veins are present in the vicinity of the radial artery . but
care must be taken to prevent vascular complications even when we perform coronary procedures using transradial access . in this case
, we report a rare case of radial avf , which developed after coronary angiography perfomed using a transradial approach . vascular ultrasound scans and ct angiography can help physicians to evaluate avf precisely .
the percutaneous transfemoral approach has been routinely used for cardiac catheterization and coronary angioplasty . 
 local vascular complications following angioplasty are seen in 5% to 10% of patients , especially in those who need prolonged anticoagulation . 
 transradial 
 access for coronary procedures dramatically reduces access site complications . we report a rare case of radial arteriovenous fistula , which developed after coronary angiography perfomed using the transradial approach 
 .