Extract

A 49-year-old man underwent orthotopic heart transplantation (HTx) for end-stage dilated cardiomyopathy with implanted cardiac resynchronization therapy defibrillator (CRT-D) removal. Laser lead extraction (LLE) was performed, but the procedure was difficult because of extensive adhesions within the vein and overcrowding.

Two years after HTx, physical examination revealed a new continuous murmur in the left subclavian area. Computed tomographic angiography showed multiple arteriovenous fistulas (AVFs) of the left subclavian vein (LSV) fed by the left internal thoracic artery (LITA) and left subclavian artery (LSA) (Panels A and B). We diagnosed iatrogenic AVFs and successfully performed endovascular repair for the AVF between the LSV and LSA with a 10 × 50 mm covered stent (Panel C; Supplementary data online, Video S1). The non-repaired AVF between LSV and LITA (Panel D, Supplementary data online, Video S2) was closely followed up.

CRT-D removal during HTx is a standard strategy because there is concern that lead retention could be associated with infection or venous thrombosis.

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