CT angiography and MR angiography in the evaluation of carotid cavernous sinus fistula prior to embolization: a comparison of techniques

BACKGROUND AND PURPOSE: This study compared CT angiography (CTA), MR angiography (MRA), and digital subtraction angiography (DSA) in elucidating the size and location of carotid cavernous sinus fistulas (CCFs) before embolization treatment. METHODS: This was a retrospective study of 53 patients with angiographically confirmed CCF. All patients underwent pre- and postcontrast-enhanced CTA and DSA, and 50 patients also underwent MRA. Two neuroradiologists rated detectability of the fistula tract as "good," "moderate," or "poor" in source images obtained by using each procedure. The chi(2) test was used to compare the imaging modalities with respect to their ability to detect fistulas. RESULTS: CTA did not differ significantly from DSA (P = .155), and both CTA (P = .001) and DSA (P = .007) performed significantly better than MRA in the population as a whole. Differences in performance among the methods, however, depended upon the segmental location of the fistula along the internal carotid artery (ICA). CTA and MRA were similar in detection of CCFs in patients with a fistula at segment 3. CTA significantly outperformed MRA in patients with a fistula at segment 4, who accounted for approximately half of the population. CONCLUSIONS: CTA source imaging has proved itself as useful as DSA for detecting CCFs. Of the 2 noninvasive techniques, CTA performed better than MRA in the population as a whole and in most patients whose fistula was located at segment 4 or 5 of the ICA.     

Increased genitourinary fistula rate after bevacizumab in recurrent cervical cancer patients initially treated with definitive radiochemotherapy and image-guided adaptive brachytherapy

Background and purpose

Patients with recurrent cervical cancer (RecCC) who received definitive radiochemotherapy including image-guided adaptive brachytherapy (IGABT) as primary treatment are currently treated in our institution with palliative intent by chemotherapy (CHT) combined with bevacizumab (BEV). We aim to evaluate the risk of gastrointestinal (GI)/genitourinary (GU) fistula formation in these patients.

Materials and methods

Data of 35 consecutive patients with RecCC treated initially with radiochemotherapy and IGABT were collected. Known and presumed risk factors associated with fistula formation were evaluated. Fistula rate was compared between patients receiving CHT or CHT+BEV.

Results

Of the 35 patients, 25 received CHT and 10 patients received CHT+BEV. Clinical characteristics were comparable. Fistulae were reported in 6 patients: two fistulae (8%) in the CHT group, four (40%) in the CHT+BEV group. GU fistula occurred in the CHT+BEV group only (3/4). Of these 6 patients with fistulae, 5 (83%) had undergone previous invasive procedures after the diagnosis of RecCC and 1 patient had undergone pelvic re-irradiation; 3/6 patients had developed a local recurrence. No other risk factors for fistula formation were identified.

Conclusion

In patients with RecCC after definitive radiochemotherapy including IGABT, the addition of BEV to CHT may increase the risk for GU fistula formation, particularly after invasive pelvic procedures. Future clinical studies are required to identify predictors for fistula formation to subsequently improve patient selection for the addition of BEV in the RecCC setting.

     

Therapeutic embolization of high-flow priapism 1 year follow up with color Doppler sonography

Objective

The aim of this study was to evaluate the use of color Doppler sonography (CDS) for the diagnosis of high-flow priapism and the treatment of cavernosal arterial fistula via super-selective arterial embolization.

Methods and materials

We reviewed eight cases of high-flow priapism with cavernosal arterial fistula, from 2005 to 2011. All of the patients were diagnosed with a high-flow priapism and unilateral artery fistula via CDS. Conventional treatments for the eight cases were unsuccessful, and the patients were then treated through super-selective embolization. Diagnostic angiograms of the internal iliac artery showed a fistula on one side of the cavernosal artery, thus confirming the CDS images. We compared hemodynamic parameters including the peak systolic velocity, end diastolic velocity the resistance index of the pathological cavernosal artery and intracavernosal pressure in all patients before and after treatment using t-test. The efficacy of super-selective embolization and the erectile function of all patients were evaluated at a follow-up time of 12 months.

Results

All patients were successfully treated and angiography showed that the fistulas disappeared after treatment. Additionally significant differences were found in the peak systolic velocity, the end diastolic velocity, the resistance index and intracavernosal pressure between pre-treatment and post-treatment (P < 0.05). At 5 days post-treatment, only one case relapses had occurred. Seven cases displayed restored erectile function and only one case exhibited erectile dysfunction.

Conclusion

Color Doppler sonography is a highly sensitive method for the examination of high-flow priapism, and super-selective embolization is a safe and effective treatment for cavernosal arterial fistula.     

Percutaneous treatment of a duodenocutaneous high-flow fistula using a new biological plug

Enterocutaneous fistula is a challenging entity and a gold-standard treatment is not settled so far. Here, we describe the successful closure of a duodenocutaneous fistula with the use of the Biodesign enterocutaneous fistula plug (Cook Medical), which is derived from a biological plug that has been used in recent years in order to close anorectal fistula tracts.Enterocutaneous fistula is defined as an abnormal communication between the small or large bowel and the skin. It is a well-known surgical complication associated with long hospital stay and high morbidity and mortality. Mortality rate varies between 5% and 20%, and it is frequently associated with sepsis and nutritional abnormalities. Spontaneous closure rate varies among studies, ranging from 7% to 70% (1). Patients unresponsive to conservative therapy require surgical repair, therefore, a treatment that could shorten fistula closure time avoiding a second operation would be highly beneficial.Recently, multiple attempts have been made to treat these patients using nonsurgical methods. Image-guided percutaneous drainage is one of the most used interventional radiological procedures, widely proven as a feasible, safe, and effective treatment of intra-abdominal abscess and fluid collections. However, the presence of a concomitant intestinal fistula remains a significant challenge and drainage has proven to be associated with a low success rate.Here, we present a case in which a biological plug was inserted percutaneously to close a duodenocutaneous fistula. This device is well known for its application in anorectal fistulas (2).     

Magnetic resonance imaging evaluation of perianal fistula

Aim of work

To clarify the role of MRI in diagnosis and classification of perianal fistula and to evaluate the additional clinical value of preoperative MR imaging and its benefit to surgeon.

Methods

This prospective study contained 25 patients (21 males and 4 females; age range 10–60 years; mean age 34.8 years) selected from 40 patients referred to the Radiodiagnosis department with perianal sepsis, the study was conducted between October 2009 and September 2011, MRIs were performed and the results were ensured by surgical results, sensitivity, specificity and predictive values of MRIs were determined.

Results

25 patients with perianal sepsis were included in this study, 3 cases grade 1 (simple linear intersphincteric fistula), 2 cases grade 2 (intersphincteric fistula with abscess or secondary track), 9 cases grade 3 (trans-sphincteric fistula), 9 cases grade 4 (trans-sphincteric fistula with abscess (5 cases), secondary track within the ischiorectal fossa (3 cases) and both (1 case)) and 2 cases grade 5 (supralevator and translevator disease one case for each).

Conclusion

MRI is a useful procedure for successful management of peri-anal fistula by correct assessment of the extent of disease and relationship to sphincter complex. Also it helps in identification of secondary extensions, particularly horseshoe tracts and abscesses resulting in complete evaluation and highest possible diagnostic accuracy aiding successful surgical interventions, aiming to reduce complications and recurrences.     

Complicated cholesteatomas: CT findings in inner ear complications of middle ear cholesteatomas

Patients with facial palsy and middle ear disease, which may be chronic but clinically occult, may have a cholesteatoma with extension medially along the facial canal. In two patients, axial computed tomographic (CT) scans demonstrated involvement of the medial petrous bone. Patients with vertigo and chronic middle ear disease may have a cholesteatoma with a "fistula" between the middle and inner ears. Although the fistula usually involves the lateral semicircular canal, the cholesteatoma may pass through the oval window. In two patients, coronal CT scans showed extension to the oval window in one and through it in the other.     

Percutaneous transluminal angioplasty of a non-mainstream venous route to restore an occluded hemodialysis fistula

Purpose

To report the usefulness of percutaneous transluminal angioplasty (PTA) of a non-mainstream venous route in an occluded native hemodialysis fistula when a mainstream outflow vein could not be traversed.

Materials and methods

This cohort included seven patients with an occulted hemodialysis fistula with difficulty in traversing via a mainstream route. A non-mainstream vein near the occluded portion was traversed until it connected with a proximal large-sized vein and the route was dilated using a 4- or 5-mm balloon catheter. Metallic stent placement was performed, if necessary. Technical aspects and long-term patency was evaluated.

Results

PTA could be performed in all patients; however, stent placement was required in two because of residual stenosis and clotting. The clinical success rate of fistula restoration was 100 %. Fistula dysfunction recurred in six patients 17–668 days (mean ± standard deviation 229.3 ± 225.0) later. PTA was repeated in four patients, but not in two. The mean duration of the primary patency was 336.6 ± 417.2 days (range 17–1,190) and that of the secondary patency was 897.1 ± 801.4 days (range 17–2,230).

Conclusion

PTA of a non-mainstream venous route is useful for restoring an occluded hemodialysis fistula when the mainstream outflow vein cannot be traversed.     

Endovascular occlusion of direct carotid cavernous fistula with detachable balloons: usefulness of 3D angiography

The objective of this study is to show rotational 3D angiography findings and their usefulness in the occlusion of carotid cavernous fistulas (CCFs) using detachable balloons. Five patients with direct CCF were retrospectively reviewed for details of interventional procedures and 2D and 3D angiography findings. Pretherapeutic 2D and 3D angiograms (n=2) were compared to evaluate the size of the fistula and the relative size of the cavernous sinus with respect to the fistula. Postinflation-predetachment (n=3) and postdetachment (n=4) 2D and 3D angiograms were compared in each stage to evaluate the relative location of the balloon to the internal carotid artery (ICA), presence of a pseudoaneurysm, and relative size of the balloon to the fistula. Pretherapeutic 2D and 3D angiograms were equally effective in showing the fistula and relative size of the cavernous sinus. But, 3D angiography with cut images at arbitrary viewing angles clearly visualized the 3D relations between the ICA, fistula, and cavernous sinus. Both postinflation-predetachment 2D and 3D images in two patients equally showed a contrast-filled pseudoaneurysm outside the ICA and intraluminal location of the balloon. However, only the 3D images showed no difference in size of the balloon compared with the fistula, which was relevant to traction-induced instability in the remaining one patient. Both postdetachment 2D and 3D angiograms were equal in terms of showing ICA compromise (60%) in one patient and an extraluminal balloon location with complete fistular occlusion in two patients. In the remainder, a small pseudoaneurysm was identified only on 3D images. Three-dimensional angiography is a useful imaging tool for capturing the complex perifistular anatomy in the pretherapeutic stage, and for providing detailed information about the degree of balloon inflation and its location, the presence of a pseudoaneurysm, and the expected traction-induced instability in the predetachment stage. Postinflation-predetachment 3D angiography may therefore offer a chance to correct an erroneous manipulation that would otherwise lead to an incomplete procedural outcome and disastrous balloon migration.     

复合手术治疗复杂硬脑膜动静脉瘘近中期效果

目的探讨复合手术治疗复杂硬脑膜动静脉瘘(DAVF)的近中期临床效果。方法回顾性分析2017年1月至2018年12月南方医科大学南方医院收治的20例DAVF患者临床资料,其中符合纳入标准的8例接受复合手术治疗。术后定期随访复查头颅CT/MRI和DSA评估瘘口闭合情况,评估神经功能、改良Rankin量表(mRS)评分变化。结果术中即刻造影显示瘘口完全闭塞7例(7/8),近完全闭塞1例(1/8)。术后2周1例因突发肺栓塞死亡。随访3~24个月,复查CT/MRI和DSA显示7例恢复良好,均无新发神经功能障碍,既往严重临床症状得到改善,mRS评分下降至2~3分。结论复合手术治疗静脉窦闭塞或多"共同通道"的复杂DAVF,可提供明确的治疗入路,通过一次全面手术使瘘口彻底永久性闭合,术后近中期临床预后较好。     

Prolonged survival of a female patient with total pelvic exenteration

BACKGROUND: To present a female patient who lived 5 years after total pelvic exenteration (TPE). CASE REPORT: The female patient underwent TPE due to retrovesicovaginal fistula as a consequence of locoregional irradiation after the operation for the malignoma of the vaginal part of the uterus. In the formation of Bricker conduit, the ureter antireflux was achieved by the application of the "tobacco sack muff" made of the intestines around the ureter. By the use of this technique, the occurrence of pyelonephritis, as the leading cause of death in such patients, was prevented. CONCLUSION: TPE is a hope for significantly prolonged survival of patients with advanced pelvic malignomas, or with a postirradiatiation fistula.     

Non-healing post-surgical fistulae: treatment with image-guided percutaneous injection of cyanoacrylic glue

Objectives

To present the results of our experience with cyanoacrylic glue percutaneous injection to treat post-surgical non-healing enteric fistulae after failure of standard treatments.

Methods

Eighteen patients (14 males; age range 33–84, mean 69 years) were treated for a non-healing post-surgical enteric fistula after failure of standard treatments. Under computed tomography and/or fluoroscopic guidance, a mixture of cyanoacrylic glue (Glubran 2, GEM, Viareggio, Italy) and ethiodized oil was injected at the site of the fistula. Fistula was considered healed when no material was drained by the percutaneous drainage and a subsequent computed tomography confirmed the disappearance of any fluid collection.

Results

In all cases, it was possible to reach the site of the fistula using a percutaneous access. A median of 1 injection (range 1–5) was performed. Fistula healing was achieved in 16/18 (89 %) patients. One patient died for other reasons before fistula healing. Median time for fistula healing was 0 days (mean 8, range 0–58 days). No complications occurred. Reoperation was needed in one patient.

Conclusions

Percutaneous injection of cyanoacrylic glue is feasible, safe, and effective to treat non-healing post-surgical enteric fistulae. It may represent a further option to avoid surgical reoperation in frail patients.

     

Role of magnetic resonance imaging in pre-operative assessment of ano-rectal fistula

Aim of the work

To evaluate the role of magnetic resonance imaging (MRI) in preoperative assessment of ano-rectal fistula and tracing its full extent and relationship.

Materials and methods

Twenty-four patients with ano-rectal fistula were enrolled in this study. They were examined with different MRI sequences for evaluation of the fistulas and their extent. Fistulas were classified according to St. James’s University Hospital MRI based classification system (which correlates the Parks surgical classification to anatomic MRI findings) into 5 grades. Then, interrelation between surgical and MRI findings was statistically analyzed with evaluation of the accuracy of each MRI sequence used.

Results

Grade 1 was the most frequent (37.5%) type of ano-rectal fistula. The most common location of the internal opening of the fistula was at 6 o’clock position. Combination of oblique coronal and axial planes of contrast-enhanced fat suppressed T1-weighed fast spin-echo (CE FS T1WFSE) sequence images showed the highest accuracy (99.4%) in diagnosis of ano-rectal fistula.

Conclusion

MRI is a useful imaging tool in the preoperative assessment of ano-rectal fistula. A significant accordance between surgical and MRI findings was achieved by using combination of coronal and axial planes of CE FS T1WFSE sequence images.     

Percutaneous transvenous packing of cavernous sinus with Onyx for cavernous dural arteriovenous fistula

Objective

The aim of this study is to describe the technique and results of the transvenous approach for occlusion of cavernous dural arteriovenous fistulas (DAVFs) with Onyx.

Methods

Eleven patients presenting with clinically symptomatic DAVFs, were treated between August 2005 and February 2007 at Beijing Tiantan Hospital. We were able to navigate small hydrophilic catheters and microguidwires through the facial vein or inferior petrosal sinus (IPS) into the ipsilateral cavernous sinus. After reaching the fistula site the cavernous sinus was packed with Onyx or combining with detachable platinum coils.

Results

We were able to reach the fistula site and to achieve a good packing of Onyx or combining with coils within the arteriovenous shunting zone in 10 patients. The final angiogram showed complete occlusion of the arteriovenous fistula. Two (18.2%) patients developed a bradycardia during DMSO injection. No complications related to the approach were observed.

Conclusions

Transvenous occlusion of cavernous DAVFs is a feasible approach, even via facial vein or via IPS. Onyx may be another option for cavernous packing other than detachable platinum coils.     

Progressive versus Nonprogressive Intracranial Dural Arteriovenous Fistulas: Characteristics and Outcomes

BACKGROUND AND PURPOSE:A minority of intracranial dural arteriovenous fistulas progress with time. We sought to determine features that predict progression and define outcomes of patients with progressive dural arteriovenous fistulas.MATERIALS AND METHODS:We performed a retrospective imaging and clinical record review of patients with intracranial dural arteriovenous fistula evaluated at our hospital.RESULTS:Of 579 patients with intracranial dural arteriovenous fistulas, 545 had 1 fistula (mean age, 45 ± 23 years) and 34 (5.9%) had enlarging, de novo, multiple, or recurrent fistulas (mean age, 53 ± 20 years; P = .11). Among these 34 patients, 19 had progressive dural arteriovenous fistulas with de novo fistulas or fistula enlargement with time (mean age, 36 ± 25 years; progressive group) and 15 had multiple or recurrent but nonprogressive fistulas (mean age, 57 ± 13 years; P = .0059, nonprogressive group). Whereas all 6 children had fistula progression, only 13/28 adults (P = .020) progressed. Angioarchitectural correlates to chronically elevated intracranial venous pressures, including venous sinus dilation (41% versus 7%, P = .045) and pseudophlebitic cortical venous pattern (P = .048), were more common in patients with progressive disease than in those without progression. Patients with progressive disease received more treatments than those without progression (median, 5 versus 3; P = .0068), but as a group, they did not demonstrate worse clinical outcomes (median mRS, 1 and 1; P = .39). However, 3 young patients died from intracranial venous hypertension and intracranial hemorrhage related to progression of their fistulas despite extensive endovascular, surgical, and radiosurgical treatments.CONCLUSIONS:Few patients with dural arteriovenous fistulas follow an aggressive, progressive clinical course despite treatment. Younger age at initial presentation and angioarchitectural correlates to venous hypertension may help identify these patients prospectively.

Intracranial dural arteriovenous fistulas (DAVFs) are rare arteriovenous shunts involving the epidural space and adjacent dura mater, which receive arterial supply from meningeal vessels and drain directly to dural venous sinuses or cortical veins.¹ In the early days of cerebral angiography, DAVFs were considered a subset of AVMs: Newton and Cronqvist² classified AVMs by arterial supply as pure dural, mixed pial-dural, or pure pial malformations. Unlike brain AVMs, however, DAVFs are most often thought to be acquired (as opposed to congenital), and DAVFs lack a nidus of vessels in the brain parenchyma. DAVF is also distinguished from nongalenic pial arteriovenous fistula by its fistula location in the dura.Management of a DAVF is based on its expected clinical course: Fistulas demonstrating cortical venous drainage (CVD) generally warrant curative therapy to prevent intracranial hemorrhage, and fistulas without CVD are managed for either symptom palliation or cure.^3–6 Treatment modalities include transarterial or transvenous endovascular embolization to occlude the arteriovenous fistula site, microsurgical interruption of the fistula site, stereotactic radiosurgery, or multimodality therapy. Endovascular procedures are used to treat a most DAVFs and are the treatment of choice for lesions accessible to catheterization.^5,6A small number of patients with DAVFs respond poorly to conventional therapies and demonstrate progressive neurologic and angiographic deterioration with enlargement of existing fistulas, formation of de novo fistulas, and development of features that increase the risk of intracranial hemorrhage.⁷ Reports of such rapidly progressive “runaway” DAVFs are scarce. Only a few cases have been published in the past 15 years; therefore, the pathogenesis, presentation, clinical course, and treatment remain unclear.^4,8–12 The purpose of this single-institution retrospective cohort study was to compare the clinical characteristics, angioarchitecture, and treatment outcomes of patients with progressive (enlarging fistulas or developing de novo fistulas) versus nonprogressive (recurrent original fistula or the presence of multiple unchanging fistulas) intracranial DAVFs.     

Transarterial treatment of direct carotico-cavernous fistulas with coils and Onyx

Introduction

The purpose of this study was to evaluate the role of combination of liquid embolic agent ethylene vinyl alcohol copolymer (Onyx) and detachable coils in the treatment of direct carotico-cavernous fistulas (CCFs).

Methods

We prospectively collected clinical and radiological data of all patients who underwent embolization of direct CCFs at our institution over a period of 21 months. The clinical parameters, angioarchitecture, presence of cortical venous reflux, volume of Onyx used, number of coils used, extent of embolization and complications were recorded.

Results

A total of 21 consecutive patients (18 men and 3 women, 14 to 48 years) with direct CCF underwent embolization with a combination of coils and Onyx. Embolization was done through the arterial route in all cases. Complete obliteration of the fistula was achieved in 19 of 21 cases. Cast embolization in middle cerebral artery occurred in one patient; however, the cast was completely retrieved with Solitaire device, and the patient did not have any neurological deficit. All completely treated patients reported relief of symptoms at varying intervals. At 6-month follow-up, none of the patients with complete occlusion of the fistula showed any recurrence.

Conclusion

The adjuvant use of Onyx with detachable coils in direct CCF through the arterial route is a safe and effective method for embolization with immediate and complete occlusion of the fistula. To the best of our knowledge, this is the first case series of demonstration of arterial use of Onyx with coils in the treatment of direct CCFs.     

Recurrent tracheo-esophageal fistula: a protocol for investigation

Following repair of esophageal atresia and tracheo-esophageal (TE) fistula, the fistula may recur in approximately 10% of patients and is often difficult to diagnose. The authors review the clinical and radiographic findings in 16 cases. Clinical findings are nonspecific; however, recurrent TE fistula may be suspected when the plain radiograph reveals an air esophagram (44% of cases), gas in the abdominal portion of the bowel (50% of those who had abdominal radiographs), or a "beaked" appearance of the anterior wall of the esophagus (50% of negative barium examinations). Oral barium studies resulted in 17 false negatives and 4 true positives, while a right lateral decubitus esophagram with a vertical beam gave 2 false negatives and 2 true positives, and a prone esophagram with a horizontal beam gave 2 true positives and no false negatives. Despite the small number of cases, the authors suggest that a prone view with a horizontal beam, rather than a decubitus examination, is the procedure of choice for recurrent TE fistulas.     

Imaging findings and endovascular management of iatrogenic hepatic arterial injuries

Iatrogenic hepatic arterial injuries (IHAIs) include pseudoaneurysm, extravasation, arteriovenous fistula, arteriobiliary fistula, and dissection. IHAIs are usually demonstrated following percutaneous transhepatic biliary drainage, percutaneous liver biopsy, liver surgery, chemoembolization, radioembolization, and endoscopic retrograde cholangiopancreatography. The latency period between the intervention and diagnosis varies. The most common symptom is hemorrhage, and the most common lesion is pseudoaneurysm. Computed tomography angiography (CTA) is mostly performed prior to angiography, and IHAIs are demonstrated on CTA in most of the patients. Patients with IHAI are mostly treated by coils, but some patients may be treated by liquid embolic materials or stent-grafts. CTA can also be used in the follow-up period. Endovascular treatment is a safe and minimally invasive treatment option with high success rates.Iatrogenic hepatic arterial injuries (IHAIs) arising from percutaneous interventions, laparoscopic or open surgery include pseudoaneurysm (PA), extravasation, arteriovenous fistula (AVF), arteriobiliary fistula (ABF), and dissection (1–3). AVF can occur between hepatic artery and hepatic vein or between hepatic artery and portal vein, called arterioportal fistula (APF). Percutaneous interventions seem to have a higher incidence of IHAIs than surgery (4). The incidence of IHAIs is more than the incidence of traumatic hepatic arterial injuries (5). Hemorrhage following an invasive upper abdominal procedure such as hepatic, pancreatic, and biliary intervention may indicate an IHAI that requires early diagnosis and treatment. Angiography is not only the gold standard imaging modality but also the first suggested treatment option with the advantage of endovascular treatment (6).The etiologies of IHAIs are percutaneous transhepatic biliary drainage, percutaneous liver biopsy, liver surgery (pancreaticoduodenectomy, laparoscopic cholecystectomy, and mass excision), transcatheter chemoembolization, transcatheter radioembolization, and endoscopic retrograde cholangiopancreatography (1–3). Mean latency period between the intervention and the diagnosis of IHAI varies. The symptoms are hemorrhage, hemobilia, and pain. Computed tomography angiography (CTA) is mostly performed prior to angiography, and IHAIs are demonstrated on CTA in most patients. Due to technical limitations of the CTA, IHAI cannot be clearly demonstrated in some patients; however, CTA can show perihepatic hematoma in these patients. CTA findings and hemodynamic status of the patients are considered to determine the indication for angiography.     

Endovascular Creation of an Arteriovenous Fistula (endoAVF) for Hemodialysis Access: First Results

Introduction

Surgical creation of a radiocephalic fistula is the gold standard of vascular access for hemodialysis. Recently, an endovascular approach for upper arm fistula creation (endoAVF) has been developed, which may be an alternative to open surgery. We describe a case series of eight cases showing feasibility, early complications and outcome of this novel treatment option.

Materials and Methods

Between July 2015 and February 2016, we created an endoAVF in eight patients. Indications for endoAVF were confirmed by a multidisciplinary vascular board upon the exclusion for Cimino fistula candidates. Patients were suitable for the procedure after a pre-therapeutic ultrasound showed adequate brachial and ulnar vessels and no ipsilateral central venous stenosis. Patient characteristics, technical success, total patient radiation dose, complication rates, time to maturation of endoAVF and clinical effectiveness at six months were assessed retrospectively.

Results

Creation of endoAVF using the everlinQ endoAVF system (TVA Medical Inc., Austin, TX, USA) was successful in all eight cases. There were one minor intraprocedural complication and no postoperative complications. Median time to endoAVF maturation was 63 days (range 26–137 days). One patient was lost to follow-up after the first monitoring visit. In the remaining seven patients, hemodialysis was started without problems. Patency after 6 months was 100%.

Discussion

The endoAVF demonstrated to be feasible and safe for the creation of arteriovenous fistula suitable for hemodialysis access. Further studies with more patients and longer follow-up periods are needed to assess long-term outcomes and comparability to surgical dialysis access creation.

     

Double spinal dural arteriovenous fistulas: case report and review of the literature

Spinal dural arteriovenous fistula (SDAVF) is the most common spinal vascular malformation. It mainly affects men after the fifth decade and is usually an acquired lesion with an unknown etiology. We report on a patient with the unusual finding of two separate SDAVFs at the level of L1 on the right and L2 on the left side. Initial selective spinal digital subtraction angiography (DSA) was terminated with demonstration of a SDAVF at the level of L1 but incomplete demonstration of all segmental arteries. Due to a recurrent deterioration of the patients neurological status, and persistent pathological vessels seen on MRI, a second spinal DSA was performed 6 years later, demonstrating the second fistula at the level of L2 on the left side with a separate venous drainage pattern. A retrospective analysis of the angiographic films suggested that both fistulas had already been present 6 years previously. This conclusion is justified because of a transient and faint opacification of the left L2 fistula demonstrated on the films after injection of the right L2 segmental artery. We conclude that in the case of incomplete angiography and persistent clinical and MR findings not only reopening of the treated SDAVF has to be taken into account but also the existence of a second fistula. Since this is the first case of a double fistula in our series of 129 SDAVFs, and given the few reported cases of double SDAVFs, we do not think that completion of selective spinal DSA has to be postulated routinely after a fistula has been found. However, repeat angiography should be performed in patients who continue to deteriorate, fail to improve with persisting MRI pathologies, or demonstrate delayed deterioration after a period of improvement.     

复杂性肛瘘的中医证型与临床资料及MRI特征的相关性研究

目的:分析复杂性肛瘘的中医证型与临床资料及MRI特征的相关性,为该病的中医辨证分型提供客观依据.方法:收集58例复杂性肛瘘的临床资料及MRI表现,包括性别、年龄、身高、体质量、体质量指数(BMI)、既往脓肿史等,记录患者中医证候及分型.MRI观察主瘘管的信号强度、内口位置、长度、深度及支管信号强度等影像学参数.结果:5...