Possible deviation in the SOC causing AV fistula during venous venoplasty and stenting of the left common Iliac vein, left external Iliac vein on subsequently requiring additional interventions in order to attempt repair.
38 y/o F with PMH: varicose veins, DVT on right, GERD, chronic anemia, right knee arthroscopy.
On12/16/2024, client had symptoms consistent with pelvic congestion syndrome with hemorrhoids, pelvic heaviness, bladder cystitis, 3 months of pain, pain during intercourse who has had a full GYN workup that is negative.
A/P:
Varicose veins-PCS is often a combination of May Thurners syndrome impeding venous outflow of the pelvic organs combined with ovarian vein reflux
Plan:
Gonadal vein embolization with IVUS of the iliac veins. If significant iliac vein compression, will plan for stenting in subsequent procedure.
On 01/09/2025 - Procedure - ultrasound guidance and Seldinger technique were utilized to access veins. A diagnostic venogram was performed due to no prior study being available. Decision to treat was based on the venography and IVUS findings. Successful Diagnostic IVUS placement/performed of L. Common Iliac vein, L. External Iliac vein, L. Common Femoral Vein, R. Common Iliac vein, R. External Iliac Vein, R. Common Femoral Vein Successful BD Venovo placement[stent]/performed of L. Common Iliac vein, L. External Iliac vein. Sheaths removed & 10-minute pressure to achieve hemostasis. No complications. RX Eliquis 5mg Twice daily x 6 months, 2 week follow up for post op US followed by ablations if needed.
01/14/2025 - follow up and unfortunately has a small AV fistula seen on US with high venous flows seen today. She has pain on her right popliteal vein and has been limping since the procedure. a/p AV fistula- Acquired fistula needs embolization-symptomatic.
03/17/2025 - Elective Admission: The patient is complaining of right posterior knee and calf pain increasing S/P popliteal access for intervention for May-Thurner syndrome, stents.1 /17/25 RLE angiogram1. Successful right lower extremity angiogram demonstrating an AV fistula between the popliteal artery and popliteal vein Assessment/Plan: Right popliteal AV fistula; discussed covered stent and open repair. Plan open repair discussed risks, benefits and indications including but not limited to bleeding, infection, myocardial infarction, DVT, nerve injury, acute closure, limb loss, and mortality. Patient is amenable to operative intervention. Procedure performed: Right femoral and popliteal angiogram, ligation of right popliteal arteriovenous fistula via posterior approach
06/27/2025 Elective Admission: Patient was known to the vascular Service, and has a history of a right popliteal AVF which underwent popliteal AVF repair on 03/17/2025. However, on recent vascular Clinic follow-up, patient reporting significant pain and persistent symptoms to the right lower extremity. patient brought in and underwent angiography with coiling. Dx: iatrogenic AVF
08/04/2025 -history of right popliteal venous access complicated by an arteriovenous fistula now status post open remediation and endovascular remediation with branch coiling with continued arteriovenous fistula and symptoms which are limiting her daily lite. We discussed in depth that these can be very difficult to treat especially now after her prior surgery and angiographic attempts. I am going to discuss this case with our interventional radiology colleagues as well as get in contact with the previous surgeon.
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Do you believe there might have been medical error?
I think it’s very start to have a fistula for stenting of the left iliac, was this measured/ivus?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I’m not sure how you can’t fix this open
What makes you a good expert for this case?
I treat May Thurner and symptomatic fistulas
How often do you encounter cases similar to this one in your practice?
Haven’t seen cases like this. But I’ve seen procedures to fix these issues
Do you believe there might have been medical error?
This is a DVT case with May Thurner syndrome. Endovenous repair and stenting is a known and well established technique. Access with Seldinger technique. It is a known complication to develop a AV fistula. This does not show any deviation from SOC. This is a rare and unfortunate complication, but still does not show a medical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is a causation between symptoms and the AV fistula. And the fistula is caused with the Seldinger access. But this does not show a medical mistake, because anytime you get access in lower extremities, you run the risk of developing an AV route. It is more common in venous sticks.
What makes you a good expert for this case?
I have done tens of thousands of Seldinger accesses. And I have run into my share of AV fistulas. They are hard to treat but treatable. If you recognize it, and follow the guidelines, you have done you SOC.
How often do you encounter cases similar to this one in your practice?
I have done tens of thousands Seldinger technique sticks in arteries and veins. AV fistulas happen. And in informed consent papers, these are all included. Patients know these things can happen. So I do not see a deviation.
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