Case report:
A 49-year-old male presented with complaints of mild swelling over the radial aspect of the right distal forearm for the last 2 months with new onset of mild pain in fingertips mainly thumb and index finger for a week (Figure 1A). He had a history of percutaneous transluminal coronary angioplasty (PTCA) 3 months back via the trans-radial route. The swelling started 1 month after the procedure. On examination superficial veins over distal forearm were prominent with thrill was palpable over swelling. Mild prolonged capillary filling time noted mainly of thumb and index fingers with no temperature change, suggestive of early ischemic changes.
Ultrasound followed by computed angiography (CT) angiography was performed for evaluation. CT revealed the complete occlusion of the radial artery from its origin till the distal forearm. The ulnar artery was normal and mild prominent. The radial artery at the wrist and proximal hand was reformed by retrograde flow from the deep palmar arch. This distal radial artery retrogradely supplying the arteriovenous fistula (AVF) at distal forearm (Figure 2A,2B).
Initially, local compression under ultrasound guidance was attempted but not successful. Since the artery was retrogradely filling from palmar arch transarterial embolization and covered stent placement was technically not feasible. Hence surgical ligation of arteriovenous fistula under supraclavicular block was performed (Figure 1B). The proximal and distal right radial artery, cephalic vein, and fistulous connection were identified and the quadruple ligation of the AVF was done. Postoperative recovery was uneventful, and the patient was discharged on the first postoperative day.