PMC6319512_01
Angiographic and schematic demonstration of high flow arterio-venous fistula within the transplanted kidney. a Aneurysmal intra renal artery (white arrow) and relative narrowing at the AVF connection (curved arrow) demonstrated on pre-procedure angiography. b Left lateral oblique view shows early draining aneurysmal renal vein (solid arrow). c Schematic diagram demonstrating the high flow AVF within the transplant kidney and highlighting the tortuous vessel anatomy
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Fig1
Ultrasound, CT angiography scan and subsequently catheter angiography demonstrated very high flow arterial venous fistula within the transplanted organ (Fig. 1), likely to be the cause of the patients symptoms of decompensated heart failure.
Series of CTA images demonstrating high flow arterio-venous fistula within the transplanted kidney. Block arrow demonstrating route of blood from transplant artery (images a-d), the AV fistula (image e) and the early filling of the transplant renal vein (image f)
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Fig2
Other salient findings were ectatic and tortuous iliac vessels (Fig. 2).
Super-selective embolisation of the AVF. a and bTransient balloon occlusion of the artery (arrow head) and common iliac vein (white arrow) to allow advancement of the sheath (solid arrow) and deployment of Amplatzer plug (curved arrow) across AVF. c Schematic diagram demonstrating the above embolisation technique
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Fig3
This balloon allowed transient occlusion of the common iliac vein (Fig. 3a), to ensure the guide wire remained in the transplant vein and not forced back into the host common iliac vein by the arterial pressure coming through the AVM. Once the wire was secured in situ, an occlusion plug (10mmx7mm) (AMPLATZER   Vascular Plug II, Abbott) was advanced through a 6F sheath and deployed across the fistula (Fig. 3b).
Angiographic demonstration of successful embolisation of AVF. The AVF (white arrow) demonstrated pre (a) and post (b & c) successful Amplatzer plug (curved arrow) occlusion, with no filling of the fistula. d Schematic diagram confirming Amplatzer plug occlusion of the AVF with no through flow
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Fig4
This led to good embolic occlusive result with subsequent angiography showing no flow across the previous fistula (Fig. 4 - (a) pre occlusion plug and (b&c) post occlusion plug).
2-month follow up CT angiogram. Pre procedure axial (a) and coronal (b) and post procedure axial (c) and coronal (d) images prove successful closure of AVF with Amplazter plug and no perfusion defect
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Fig5
Follow up CT Angiogram performed 2 months after procedure confirmed good perfusion of transplanted kidney, stable position of the occlusion device at AVF site and resolution of the previous AVF (Fig. 5).