(Circulation. 1998;98:375.)
© 1998 American Heart Association, Inc.
Images in Cardiovascular Medicine |
"The Thrill is Gone"
Visualization and Treatment of an Arteriovenous Fistula
James N. Topper, MD, PhD;
Joshua A. Beckman, MD;
Reza Malek, MD;
Michael Meyerovitz, MD;
; Mark A. Creager, MD
From the Cardiovascular Division, Department of Medicine (J.N.T., J.A.B.,
M.A.C.), and the Department of Radiology (R.M., M.M.), Brigham and
Women's Hospital, Boston, Mass.
Correspondence to Mark A. Creager, MD, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02115.
An 87-year-old woman
underwent placement of a permanent pacemaker for recurrent near-syncope
and sick sinus syndrome. Left subclavian vein access was difficult to
obtain despite multiple attempts, and the pacemaker was ultimately
placed on the right side. After surgery, the patient developed a
mediastinal hematoma necessitating transfusion. No other acute
interventions were required. Over the next 8 weeks, the patient
developed progressive fatigue, weakness, exertional dyspnea, and
lower-extremity edema. The pacemaker was functioning normally.
Diuretic and ACE inhibitor therapies were
instituted, which improved but did not resolve the patient's symptoms.
The patient was referred to our institution for further evaluation.
The blood pressure was 105/80 mm Hg, and the
heart rate was 72 bpm and regular. The lungs were clear to
auscultation. A prominent thrill was appreciated adjacent to her left
clavicle. A loud to-and-fro bruit was audible across her
precordium.
The patient underwent angiography, which revealed an arteriovenous
fistula. The arteriogram on the left is a visualization of the left
subclavian artery and its branches, demonstrating a fistula between the
left internal mammary artery (large arrow) and the left
subclavian/brachiocephalic vein (small arrow). The left internal
jugular vein is seen to be filling in a retrograde fashion. After coil
embolization, the left internal mammary artery is occluded (right,
arrow), and no venous structures are seen during arterial
injection. The thrill was not palpable after the procedure. The patient
was discharged the next day, and all of her symptoms resolved over the
next week.
Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.
