Unusual congenital coronary arterio-venous fistulae with surgical correction

A typical case of anginal syndrome in a fifty year old male has been described. The underlying lesion was congenital coronary arterio-venous fistula between the left anterior descending branch of the left coronary artery and pulmonary artery. Diagnosis has been made by coronary angiography and proved at operation. The patient underwent successful operation where a multiple fistulous ostia draining into the pulmonary trunk were obliterated by means of extracorporeal circulation. The pertinent literature related to this congenital anomaly and symptomatology has been reviewed.     

Restoration of acutely thrombosed arterio-venous fistulae by rTPA and percutaneous angioplasty

Acute thrombosis in native arterio-venous fistulae (AVF) results in considerable patient morbidity. Interventional radiology (IR) comprising thrombolysis and percutaneous transluminal angioplasty (PTA) is well established in the management of thrombosed polytetrafluoroethylene (PTFE) grafts. However its role in thrombosed AVF is uncertain. We looked retrospectively at the role of IR in re-establishing blood flow in acutely throm-bosed AVF. Between 1992-2000, 21 episodes of acutely thrombosed AVF in 15 patients (9 females; age range 29-80yrs) were referred for intervention. All fistulae were being used for haemodialysis at the time. Diagnosis was established by angiography and thrombolysis with recombinant tissue plasminogen activator (rTPA) was attempted in all patients. Discrete stenoses when present (n=12) were then treated with PTA and resistant or recurrent stenoses were managed by stent insertion (n=3). Patients were then heparinised for 24 hours. Technical success as defined by radiological patency was achieved in 86% cases. Clinical success i.e. the ability to reuse of the fistula for haemodialysis was achieved in 62% of the interventions, where patency rates at 3 and 6 months were 92% and 69% respectively. Five patients had recurrence of thrombosis >3 months after the primary procedure, 3 had successful reintervention. Minor local bleeding was the only complication. Our retrospective study shows rTPA and PTA is successful in the management of acutely thrombosed AVF. We advocate the routine use of IR as a valuable technique for prolonging the life of native AVF in patients on maintenance haemodialysis.     

Natural history of upper limb arterio-venous fistulae for chronic hemodialysis

Purpose: Arterio-venous fistulae (AVF) for hemodialysis are prone to problems, ultimately leading to failure of the fistulae. Our aim was to determine the site and time to first stenosis and time to and factors influencing AVF failure for radio-cephalic (RC), brachio-cephalic (BC), and transposed brachio-basilic (BB) AVF. Methods: Retrospective analysis of native AVF constructed within a single vascular unit between January 2002-December 2008. Patients followed up to the end points of death, AVF failure or end of study period. Data collected included: age, sex, AVF type, time and site of first stenosis and time to failure. The relationship between fistula type, stenosis, and failure were examined. Results: In total, 398 native AVF were included in the study (91 RC, 208 BC, and 99 BB), with a mean age of 66 years. A total of 215 (54%) AVF developed a flow limiting stenosis, and over time 151 (40%) AVF failed. Stenoses developed significantly earlier in RC AVF (median 113 days) compared to BC (median 277 days), compared to BB (median days 414), P=.029. There was no statistically significant difference in time to failure (RC median 1344 days; BC median 1576 days; BB median 1159 days), P=.673. The presence of stenosis was the only variable found to have a significant impact on AVF failure in multivariate analysis. Conclusions: Type of upper limb fistula did not impact on failure rates. Flow limiting stenoses impacted on fistula failure.     

Non-surgical salvage of thrombosed arterio-venous fistulae: a case series and review of the literature

Attempts to salvage thrombosed hemodialysis arterio-venous fistulae (AVF) using interventional techniques are not universally performed. Patients often require temporary dialysis catheters pending creation of a new vascular access. We determined the long-term outcome of interventional (non-surgical) repair of completely thrombosed AVF in 49 consecutive accesses (22 radio-cephalic, 1 radio-basilic, 19 brachio-cephalic, and 7 brachio-basilic) referred for an intervention within 48 hours of thrombosis. Subjects were 65% male (32), with mean +/- SD age 63.7 +/- 13.5 years (range 33-91), 51% African-American (25), 47% Caucasian (23) and 65% had diabetes (32). Overall, 96% (47/49) of thrombosed AVF were salvaged with complications observed in four cases (two extravasations of contrast; two radial artery emboli), with no serious long-term sequelae. Interventional procedures included 34 venous angioplasties, 11 venous angioplasties with stenting and two combined venous and arterial angioplasties. The primary and secondary patency rates for all salvaged AVF were 50.5 +/- 8.7%, 72.5 +/- 7.8% at 1 year, and 43.3 +/- 10%, 55.4 +/- 12.7% at 2 years, respectively. The median estimate to first intervention after the declot procedure was 14.7 months. The median estimate for continued function exceeded 23.1 months. There was no significant statistical difference in the primary (p = 0.73) and secondary patency rates (p = 0.057) for forearm vs. upper arm AVF. We conclude that interventional repairs should routinely be employed to salvage newly thrombosed AVF. The vast majority of these individuals can avoid receiving dialysis catheters or placement of a new dialysis vascular access.     

Interest and necessity of combined neuroradiological and neurosurgical treatment in some cases of dural arterio-venous fistulae

Summary The authors report 3 observations of dural arterio-venous fistula cured by combined neuroradiological and neurosurgical intervention. In the first case, the shunt affected the left lateral sinus. Repeated embolizations failed whilst intracranial hypertension developed, as a consequence of flux in the opposite lateral sinus and in the sagittal sinus. Surgical intervention, consisting in isolation of the transverse sinus, led to complete cure, after a one month delay. In the second case, the shunt was adjacent to the sagittal sinus, right pariet al, and had led to an intracerebral haematoma, by rupture of an arterialized cortical vein. Embolizations alone could not cure the fistula which therefore had to be excised. In the third case, the shunt was located in the falx, at the parieto-occipital junction, and was responsible for arterialization of cerebral veins in the right parieto-occipital region. For this reason, after failure of endovascular treatment, the fistula was coagulated, with subsequent complete cure.These three cases illustrate the different types of drainage of such arterio-venous fistula, and their corresponding neurological symptoms and signs, complications and risks, that required a radical — not only clinical, but also anatomical — cure. This aim was achieved when embolizations were accompanied by direct surgical attack.     

The correlation between clinical and duplex ultrasound parameters and the development of complications in arterio-venous fistulae for haemodialysis

In a 2 year prospective study of the fate of arterio-venous haemodialysis fistulae, the influence of several clinical and non-invasive measured variables in 90 patients on maintenance haemodialysis was evaluated. A total of 58 Brescia/Cimino fistulae, 30 graft fistulae and two elbow fistulae were investigated by means of Duplex ultrasound scanning. Sixty-two out of these 90 patients had no problems with their AV fistulae, 28 developed 29 complications, including poor flow (six), thrombosis (seven), venous hypertension (eight), false aneurysm formation (four), distal ischaemia (two) and puncture problems (two). Univariate statistical analysis was performed on a number of clinical variables including diabetes, previous access surgery, type of fistula, duration of functioning fistula, congestive heart failure, peripheral arterial disease, age and sex. Results indicated that the type of fistula, previous access surgery, congestive heart failure and sex were significantly correlated to the development of poor flow and thrombosis (flow-related complications). Measurement of the maximal systolic frequency, end-diastolic frequency and the frequency ratio in the brachial artery Doppler spectrum, was of prognostic value in discriminating between non-complicated fistulae and those which developed flow-related complications. The total number of fistula stenoses (greater than 50% diameter reduction), detected by the Duplex scan, also correlated with the rate of thrombosis and poor flow. The presence of peripheral arterial disease and the number of stenoses in the efferent veins were of predictive value for the development of venous hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)     

Embolisation of indirect carotid-cavernous sinus dural arterio-venous fistulae using the direct superior ophthalmic vein approach

Summary  Indirect carotid-cavernous sinus dural arterio-venous fistulae (cDAVF) can be treated by transarterial and/or transvenous embolisation. This study evaluated patients with cDAVF who underwent transvenous embolisation using the direct superior ophthalmic vein (SOV) approach. Between January 2004 and October 2006, eight cDAVF in seven patients were embolised using direct surgical exposure of the SOV when access to the cDAVF via transarterial or transfemoral venous routes was not feasible. Medical records and imaging studies were retrospectively reviewed. The seven patients consisted of four females and three males from 43 to 65-year-old (mean age, 54.4 years). Six cDAVF lesions were located on the left side and two on the right. All fistulae were successfully embolised and showed clinical improvement. One patient presented after treatment with transient venous congestion on the brain stem, which was relieved by osmotic diuretics and steroids. Direct surgical exposure of the SOV for transvenous embolisation of cDAVF can be effective if the facial vein, inferior petrosal sinus, and internal jugular vein are thrombosed. This approach is easy, safe, and effective when performed by a multidisciplinary team. Correspondence: Jae-Whan Lee, Assistant Professor, Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, 134 Shinchon-dong Seodaemun-gu, Seoul 120-752, Korea.     

Surgical treatment of spinal dural arterio-venous fistulae: long-term results and analysis of prognostic factors

Summary   Background. Spinal dural arterio-venous fistulae (SDAVF) are slow-flow extramedullary vascular lesions which account for 75–80% of all spinal vascular malformations. At present there is no agreed view with regard to the best therapeutic option being surgical or endovascular, and several reports favour one or other form of management. This is so because of lack of consistent literature, as well as knowledge, concerning the long-term clinical outcome of the patients. The objective of this study is to retrospectively analyse the results obtained with patients operated for a SDAVF at the Department of Neurosurgery of Verona during a 15-year period and to evaluate possible prognostic factors related to neurological outcome. Patients and methods. Between January 1987 and May 2002, 29 patients with SDAVF were operated at the Department of Neurosurgery of Verona. For 25 of these patients we were able to obtain a clinical follow-up using telephone interviews. The patients were evaluated with the Aminoff and Logue’s scale and subsequently stratified into three classes of disability. An overall score (gait and micturition, G + M) of 0–3 indicates a mild disability, a score between 4 and 5 indicates a moderate disability and a score between 6 and 8 a severe disability. All patients underwent surgical treatment which was mainly the first therapeutic option. Following surgery, the patients were re-evaluated with the same neurological scale. We also investigated with statistical analysis the possible impact on clinical outcome of the major clinical, neuroradiological and surgical variables. Results. The epidemiological, clinical, radiological and pathological features of our group of patients are very similar to those previously described in the literature. For 10 patients surgery consisted simply of the interruption of the intradural arterialised draining vein (with or without closure of the small extradural arterial afferents), whereas in the remaining 15 patients coagulation or excision of the fistolous dura was also accomplished. At the last follow-up (mean 7.3 years; in 19 patients longer than 5 years), 10 patients had improved (40%), 11 were stable (44%) and 4 had deteriorated (16%). We determined that only the pre-operative neurological status, described by the G value in the Aminoff and Logue’s scale and the class of disability, had an impact on clinical outcome. Conclusions. This retrospective study confirms that the surgical treatment results of SDAVF are satisfactory even if evaluated after many years. Given these results, and in accordance with the majority of the literature, we concur that surgery should be the first choice treatment for these spinal vascular lesions in order to avoid a dangerous delay and consequently further neurological deterioration. In our group of patients the only prognostic factor statistically related to clinical outcome was the pre-treatment neurological status, particularly the grade of paraparesis and the class of disability. Correspondence: Dr. Paolo Cipriano Cecchi, Operative Unit of Neurosurgery, Regional General Hospital, Via Boehler 5, 39100 Bolzano, Italy.     

Pulmonary embolism, an unrecognized risk of post-traumatic arterio-venous fistulae of the hepatic veins (1 case)]

A stab wound of the right lobe of the liver, initially treated by suture, led to the development of a large arterio-venous fistula with hemobilia. Re-operation on the 23rd day in order to carry out right hepatectomy, was rapidly followed by a massive and recurrent pulmonary embolism. A Trendelenburg operation associated with right hepatectomy did not prevent the patient's death. This risk of pulmonary embolism during post-traumatic hematoma of the liver is not fully recognised and the authors suggest, in cases of arterio-venous fistula of the hepatic veins, primary vascular exclusion of the supra-hepatic vena cava.     

The management of aneurysms and arterio-venous fistulae of the popliteal artery arising from war trauma. Emphasis on sigmoid operative approach

Between 1986-1988, 600 vascular cases arising from the Iran-Iraq conflict were dealt with within an 18 month period and 60 cases of popliteal artery and/or venous disruption were encountered presenting at variable times after injury. A policy of management between the forward and base hospital surgical teams was introduced, observing the following broad categorizations: (a) assessment/referral, (b) assessment/fasciotomy/referral, (c) immediate operation/referral for further operation/review/management. Two types of incision were used to enter the popliteal fossa: (a) a medial incision and (b) a sigmoid posterior incision (which we now favor). The results of this strategy of management and operative technique (when compared with our previous experience within the same time frame) suggested an improved outcome. Fifty-four out of 60 cases had a satisfactory operative result with below-knee amputation being required in only four cases and higher amputations in two others. No operative or postoperative deaths occurred. The implementation of this "vetting policy" at the front line appeared to reduce the number of amputations and assisted the clarification of management criteria in assessing limb viability at the forward hospital when a large number of casualties were being received. Operative access using the sigmoid posterior incision was not associated with any complications, offered better exposure than the medial incision and was technically easier for the surgeon to perform.     

Pathogenesis of degenerative-dystrophic changes in the hip joint

The authors have examined 43 children by the method of radiotropic angiography, 27 of whom had various diseases of the hip joint area. The blood flow in the iliac vessels and the regional blood flow in the area of the affected vessels was studied before and after the operation making use of an osteotropic radiopharmacological drug (RPD) 99mT-phosphon. Independent of the character of the degenerative and dystrophic process in the hip joints there was a reduction in the intensity of the blood flow on the affected side reaching 15-30%, which was more expressed at stage 111 of coxarthrosis with no considerable changes after the operation. In the control group this difference was +/- 5%. The regional blood flow (RBF) in the area of the operation was reduced down to 37% before the operation and increased by 17-35% 6-8 months after the operation with the exception of the cases of dystrophic lesions of the neck when no increase in the RBF was observed. The authors come to the conclusion about a relationship between the deviation from the normal conditions in the intensity of the blood flow and the degenerative and dystrophic processes in the hip joints.     

Semen parameters in men with spinal cord injury： changes and aetiology

Aim： To assess the changes in semen parameters in men with spinal cord injury （SCI） and the possible causes of these changes. Methods： The study included 45 subjects with SCI. Semen retrieval was done by masturbation （2）, vigorous prostatic massage （n = 13）, penile vibratory stimulation （n = 13） or electroejaculation （n = 17）. Results： The semen of men with SCI showed normal volume （2.3 ± 1.9 mL） and sperm count （85.0 × 10^6 ± 83.8 × 10^6/mE） with decreased motility （11.6% ± 10.1%）, vitality （18.5 % ± 15.2%） and normal forms （17.5 ± 13.4%）, and pus cells has been increased （6.0 × 10^6 ± 8.2 × 10^6/mL）. Total （13.4 ± 9.9 vs. 7.1 ± 6.8） and progressive （4.4 ± 3.9 vs. 2.2 ± 2.1） motility were significantly higher in subjects with lower scrotal temperatures. There was no statistical significant difference between electroejaculation and penile vibratory stimulation groups as regards any of the semen parameters. Subjects＇ age, infrequent ejaculation, injury duration and hormonal profile showed no significant effect on semen parameters. Conclusion： The defining characteristics of the seminogram in men with SCI are normal volume and count with decreased sperm motility, vitality and normal forms, and the increased number of pus cells. The most acceptable cause of the deterioration of semen is elevated scrotal temperature.     

Role of somatostatins in the preventin of pancreatic fistulae and the treatment of digestive fistulae

Somatostatin and analogues exert an extraordinary range of inhibitory effects which eventually may have a variety of therapeutic applications. Treatment of intestinal and pancreatic fistula are the main targets in general and digestive surgery. The perioperative and prophylactic application of somatostatin or octreotide in patients who undergo major pancreatic surgery reduces the postoperative complication rate. This prevention seems indicated following Whipple procedure in patients with soft pancreatic tissue. The efficacy of somatostatin or analogues in the treatment of intestinal or pancreatic fistulae is still in debate. Fistula output frequently decreases but closure rate, healing time and complications rate are not reduced. The treatment and care of patients with high output fistulae may be simplified by somatostatin or analogues if a positive effect on output is obvious in the first days of treatment.