# An Anterolateral Popliteal Artery Puncture Resulting in an Arteriovenous Fistula Involving Three Vessels: Bail Out by Balloon Hemostasis

## TL;DR

A rare case of an arteriovenous fistula after a popliteal artery puncture was successfully treated with balloon hemostasis.

## Contribution

Demonstrates a successful bail-out technique using balloon hemostasis for a complex vascular complication.

## Key findings

- Arteriovenous fistulas formed between the fibular artery and two veins after anterolateral popliteal artery puncture.
- Balloon hemostasis effectively resolved the arteriovenous shunts without recurrence over four years.
- Inexperienced punctures and low insertion sites increase the risk of such complications.

## Abstract

The anterolateral popliteal artery (PA) puncture technique is mainly used during endovascular therapy of the superficial femoral artery when antegrade wiring fails to pass the wire through the true lumen of the distal artery. This method has many advantages, such as allowing puncture while the patient is in the supine position and relatively easy hemostasis; however, the distance from the body surface to the PA is long, and puncture requires practice. In this case, the distal artery approach was performed for the treatment of chronic occlusive lesions in the left superficial femoral artery. We performed anterolateral PA puncture, inserted a 4.0-Fr sheath, and successfully achieved revascularization using a controlled antegrade and retrograde tracking (CART) technique. Post-procedural angiography after sheath removal revealed an arteriovenous fistula between the fibular artery and fibular vein and another arteriovenous fistula between the fibular artery and the anterior tibial vein. After adding two 10-minute balloon hemostasis, the arteriovenous shunt almost disappeared, and there was no recurrence of the arteriovenous shunt thereafter. The patient has been an outpatient for four years with no recurrence of arteriovenous shunts. Repeated punctures due to inexperience with anterolateral PA puncture and the insertion of a sheath at a low peripheral site may increase the risk of arteriovenous fistula. Becoming skilled at puncture and puncturing the PA at the height of the fibular head can reduce the risk of arteriovenous fistula.