1. ¹Department of Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
2. ²Department of Surgery, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada

Correspondence: A K Kew, E-mail: andrea.kew@cdha.nshealth.ca

The use of peripheral blood progenitor cells following G-CSF administration for allografting has increased dramatically in the last decade in both the related and unrelated settings. Although generally safe, peripheral blood progenitor cell donation has been associated with adverse events. Most events are related to the use of growth factors to mobilize progenitor cells and include bone pain, headache, nausea, myalgias and local reactions at the injection site.^{1, 2} Rarely, the use of G-CSF has been associated with splenic rupture in normal donors.^{3, 4} Apheresis is also associated with complications including hypotension, hypocalcemia and venipuncture complications.⁵ In a retrospective review of 2386 apheresis donors, 0.53% experienced venipuncture-related complications including hematoma development, pain or swelling at the venipuncture site, venous infiltration or peripheral neuropathy.⁵ An additional review reported venipuncture complications in 1.15% of apheresis donations.⁶

We describe a volunteer donor who developed an arteriovenous fistula after peripheral blood progenitor cell donation. The donor is a 23-year-old healthy woman. She received G-CSF 10 g/kg/day subcutaneously for 5 days followed by a single standard volume (12 L) apheresis. A peripheral venous catheter was placed in each antecubital fossa without difficulty and the apheresis procedure was well-tolerated and uncomplicated.

One month following the procedure, the donor noted a vibration in her left arm. She was otherwise well. There was an easily palpable thrill and a bruit in the left antecubital fossa. Non-invasive vascular diagnostic testing using Doppler ultrasonic imaging demonstrated a small arteriovenous fistula with high velocity flow. In the left brachial artery, there was increased diastolic flow compared to the right brachial artery (Figure 1a). These findings correlated with concomitant abnormal continuous flow in the left brachial vein (Figure 1b). There was no decrease in distal arm blood pressure with essentially normal Doppler flow patterns in both the distal radial and ulnar artery. On the basis of these findings, it was decided to observe for a 6-month period without surgical intervention.

Figure 1.

(a) Doppler ultrasound showing increased diastolic flow in the left brachial artery. (b) Doppler ultrasound showing abnormal continuous flow in the left brachial vein.

Full figure and legend (281K)

Carotid-jugular arteriovenous fistula formation has been described as a complication of internal jugular vein catheterization.⁷ Femoral arteriovenous fistulae are also described following percutaneous femoral arterial catheterization.⁸ To our knowledge, this is the first report of arteriovenous fistula formation after peripheral venous catheterization for allogeneic peripheral blood progenitor cell collection. It is notable that establishing venous access was neither difficult nor traumatic in this donor. We postulate that treatment of the donor with G-CSF may have promoted endothelialization and fistula formation. Animal models have demonstrated that G-CSF treatment results in increased circulating vascular endothelial cells and accelerates re-endothelialization in injured arteries.^{9, 10}

In the context of informed consent, it may be appropriate to consider the potential risk of arteriovenous fistula formation when discussing the risks and complications of G-CSF-stimulated peripheral blood donation in potential donors.