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Justyna Rybicka, Mirosław Kowalski, Marcin Demkow, Piotr Dobrowolski, Piotr Hoffman, Multiple congenital arteriovenous fistulas draining into the right internal mammary vein with a large internal mammary varicose vein, European Heart Journal - Cardiovascular Imaging, Volume 17, Issue 9, September 2016, Page 1067, https://doi.org/10.1093/ehjci/jew115
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A 35-year-old asymptomatic woman was referred for percutaneous closure of patent ductus arteriosus (PDA). Loud continuous murmur at the left and right sternal border was detected. Successful percutaneous closure of PDA with an Amplatzer 9-PDA-005 Duct Occluder was performed. The next day, however, loud continuous murmur was still present. Echo showed Amplatzer Duct Occluder in the site of PDA. CT demonstrated arteriovenous fistula between right subclavian artery and right internal mammary varicose vein (Panels A, B, C, and E). On a subsequent echo, arteriovenous fistula with a continuous flow in the right subclavian area was visualized (Panel J). Repeated catheterization revealed congenital arteriovenous fistula between right subclavian artery and right internal mammary vein (Panels D and F, see Supplementary data online,Supplementary Data), as well as vascular net connecting right internal mammary artery (Panel G, see Supplementary data online,Supplementary Data) and branches of right axillary artery (Panel H, see Supplementary data online,Supplementary Data) with large tortuous internal mammary varicose vein draining into the right brachiocephalic vein, also seen in CT (Panel I). Patient underwent percutaneous closure of the fistula between right subclavian artery and right internal mammary vein using Amplatzer Vascular Plug 10 mm. Occluder was placed directly behind the proximal balloon-like dilatation of the right internal mammary varicose vein (see Supplementary data online, Video S6). Implantation of a covered stent in the right subclavian artery was abandoned due to close relation of the right internal jugular vein to the origin of the fistula. Because of the leak through the plug, 1 month later Amplatzer Vascular Plug 6 mm was implanted below the one previously inserted. Subsequently, fistula originating from the right internal mammary artery was closed with Amplatzer Vascular Plug 4 mm.
