Percutaneous treatment of a large superior mesenteric artery pseudoaneurysm and arteriovenous fistula: a case report

The combination of superior mesenteric artery (SMA) pseudoaneurysm and arteriovenous (AV) fistula is a rare complication following penetrating abdominal trauma. We report a case of a post-traumatic SMA pseudoaneurysm and large fistula between the SMA and superior mesenteric vein (SMV), which was successfully treated with an endovascular stent graft.     

透析用上肢自体动静脉内瘘的临床研究

目的:探讨3种透析用自体动静脉内瘘的优点以及不足,为其在临床的应用和维护提供参考。方法:63例行自体动静脉内瘘术患者根据内瘘类型为鼻烟窝内瘘组(20例),腕部内瘘组(25例)和肘窝部内瘘组(18例),分析并比较3组患者术后的血栓形成、假性动脉瘤和高输出量心衰的发生率及平均吻合口直径和平均内瘘血流量。结果:全组术后血栓形成7例,取栓后继续透析,其中腕部内瘘组5例在术后1年内发生内瘘失功而改行对侧前臂内瘘或肘窝部内瘘;腕部和肘窝部内瘘组各有1例发生高输出量心衰,经手术缩小吻合口径后好转;1年后彩超复查,3组内瘘血流量均>300 mL/min。3组间比较显示,腕部内瘘组的血栓形成的发生率(5/25)高于鼻烟窝内瘘组(1/20)和肘窝部内瘘组(1/18),肘窝内瘘组的假性动脉瘤的发生率(7/18)高于鼻烟窝内瘘组(2/20)和腕部内瘘组(3/25)(均P<0.05),高输出量心衰的发生率各组间无明显差异(P>0.05);肘窝部内瘘组吻合口直径与内瘘血流量均高于鼻烟窝内瘘组与腕部内瘘组(均P<0.05)。结论:鼻烟窝内瘘可作为血管条件较好的透析患者的首选手术方式,肘窝部内瘘是血管条件较差和前臂内瘘失功后的选择。     

Transarterial coil embolization of a high-flow vertebrojugular fistula due to penetrating craniocervical trauma: case report

BACKGROUND: Vertebrojugular fistulas after penetrating cervical trauma (gunshot or stab wounds) are rarely reported. Successful endovascular coil embolization of an acute fistulizing vertebral artery pseudoaneurysm involving an obstructed internal jugular vein is presented and the various treatment strategies for such a lesion are described. CASE DESCRIPTION: A 23-year-old man presented from an outside institution after sustaining 2 gunshot wounds in a civilian conflict. Neuroimaging revealed a right vertebral artery pseudoaneurysm, which formed a fistulous connection with the internal jugular vein. Because venous outflow obstruction was present just below the fistula, a high-flow shunt was directed intracranially. Both the pseudoaneurysm and arteriovenous fistula were accessed percutaneously via a transfemoral route and coil embolization was performed. Perfusion of the basilar artery circulation was assumed by the contralateral vertebral artery. The ipsilateral posteroinferior cerebellar artery filled through retrograde flow down the vertebral confluence. CONCLUSIONS: Coil embolization is a safe and reliable strategy by which to obliterate an acute traumatic vertebrojugular fistula as well as pseudoaneurysm. Serial angiographic follow-up is mandatory to document a persistent cure.     

Hemodynamically relevant hematuria several months after biopsy of a kidney graft: an unusual cause

We report the case of a 52-year-old female patient, who after a complicated living donor kidney transplantation, underwent kidney biopsy for suspected rejection. Duplex scanning revealed a small, asymptomatic arteriovenous (AV) fistula which was assessed as being hemodynamically unimportant. During follow-up, several urinary tract infections occurred and recurrent short episodes of hematuria were attributed to cystitis, urethritis and urosepsis. Eight months later, the patient developed suddenly massive hematuria, tamponade of the urinary bladder and hemorrhagic shock as well as urosepsis. Duplex sonography showed a massive pseudoaneurysm in addition to the AV fistula. Arteriography confirmed the Duplex sonographic findings and embolization was performed after treatment of concomitant urosepsis. The fistula was closed completely and bleeding ceased. Although AV fistulas are rare complications of kidney biopsies and in most cases they remain asymptomatic, life-threatening hematuria can present several months after a biopsy due to the development of a pseudoaneurysm. Concomitant infectious complications of the urinary tract, bleeding disorders and other factors can be misleading during the assessment of the cause of gross hematuria. Regular Duplex sonographic follow-up examinations in patients with AV fistulas are advisable.     

Hemodynamic analysis of associated extracranial atraumatic vertebral artery aneurysm and arteriovenous fistula. Case report

A case of atraumatic arteriovenous (AV) fistula of the extracranial vertebral artery associated with an atraumatic aneurysm of the contralateral extracranial vertebral artery is reported. The fistulous lesion was excised after distal and proximal ligation of the vessel. Subsequently, the contralateral aneurysm underwent spontaneous dissolution. Seven cases of extracranial vertebral AV fistulae associated with ipsilateral vertebral artery aneurysms (four traumatic and three as part of vascular dysplastic syndromes) have been reported previously.     

Vertebral artery injury--diagnosis and management

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.     

Traumatic vertebro-vertebral arteriovenous fistula manifesting as radiculopathy. Case report

A 58-year-old man presented with a traumatic vertebro-vertebral arteriovenous fistula (VVAVF) after attempting suicide by thrusting scissors into his right anterior cervical region. Two months later he noticed weakness and numbness of the right upper extremity. Examination revealed bruit in the right neck, no cranial nerve palsy, and weakness of the right deltoid and biceps muscles. Hypalgesia and hypesthesia were noted in the right C5 and C6 dermatomes. Magnetic resonance imaging demonstrated a mass lesion on the right ventral aspect of the spinal canal from C2 to C7. Right vertebral artery angiography showed a pseudoaneurysm of the right vertebral artery and a high-flow arteriovenous fistula between the right vertebral artery and vein. The right vertebral artery was occluded with detachable coils because the fistula showed high blood flow and the right posterior inferior cerebellar artery was well opacified from the left vertebral artery. This procedure resulted in complete obliteration of the arteriovenous fistula. The preoperative motor and sensory symptoms improved. Endovascular treatment by coil embolization was effective in our patient with traumatic VVAVF.     

Pseudoaneurysm after revision total knee arthroplasty

Arterial vascular complications following knee replacement are uncommon with reported incidence ranging from 0.03 to 0.12%. The complication rate is rising with increased number of primary and revision total knee replacements. Vascular complications following TKR can result in arterial thrombosis, AV fistula, haemorrhage, pseudoaneurysm and arterial transection. They are associated with significant morbidity and can be limb-threatening. Early recognition and management of vascular injury is essential although some times its presentation may be delayed. We report a case of pseudoaneurysm arising from inferior lateral genicular branch of the anterior tibial artery after revision right total knee replacement.     

Percutaneous endourology: vascular complications

Summary Bleeding may occur at any point during percutaneous nephrostomy tube placement or stone removal. Venous bleeding is readily manageable and is not a serious complication. Arterial bleeding secondary to AV fistula formation and pseudoaneurysm formation is a serious complication of percutaneous stone removal and demands emergency treatment. Patients should undergo areteriography with embolization of the peripheral vessel. The incidence of this problem is about 0.5%.     

Traumatic anterior communicating artery pseudoaneurysm with cavernous sinus fistula

A traumatic carotid-cavernous fistula and an intracranial pseudoaneurysm are uncommon but well-known complications of head trauma. A rare subtype of arteriovenous fistula may occur from a pseudoaneurysm of the anterior communicating artery (AcoA) instead of the internal carotid artery. We describe a patient with a traumatic pseudoaneurysm of the AcoA with a cavernous sinus fistula treated with endovascular treatment. A 68-year-old man presented with a severe head injury after a fall. Coronal view multiplanar reformatted images with contrast medium showed gradual expansion of the pseudoaneurysm of the AcoA and the enhanced area of the cavernous sinus. Five weeks after the injury, the patient had a subarachnoid hemorrhage. A cerebral angiogram showed a fistula between the pseudoaneurysm of the AcoA and the cavernous sinus. The AcoA, left anterior cerebral artery and part of the pseudoaneurysm were obliterated by coil embolization. A postoperative angiogram showed no flow through the pseudoaneurysm and the cavernous sinus fistula. A traumatic AcoA pseudoaneurysm with a cavernous sinus fistula may occur as an extremely rare complication of head injury.     

Spontaneous disappearance of arteriovenous fistula between the vertebral artery and deep cervical vein--case report.

A 58-year-old female was readmitted with pulsatile tinnitus in the right ear 8 months after subtemporo-occipital transtentorial clipping of a peripheral superior cerebellar artery aneurysm. On examination, she was normal except for pulsatile bruit over the right mastoid region. Angiography showed a fistulous communication between the muscular branches of the right vertebral artery and the deep cervical vein. The incision of the aneurysm surgery was supratentorial, so the only possible cause of the upper cervical arteriovenous (AV) fistula was fine gold acupuncture needles implanted for bronchial asthma 18 years before. The AV fistula disappeared spontaneously after 1 month, possibly because of thrombosis of the affected veins.     

Three-dimensional contrast-enhanced magnetic resonance angiography (3-D CE-MRA) in the evaluation of hemodialysis access complications, and the condition of central veins in patients who are candidates for hemodialysis access

BACKGROUND: Arteriovenous (AV) fistulas are crucial in patients requiring long-term hemodialysis (HD). Dysfunctions of these fistulas are the most common causes of recurrent hospitalizations. This study aimed to evaluate the feasibility, safety and usefulness of contrast-enhanced magnetic resonance angiography (CE-MRA) in the evaluation of HD fistulas complications, and the condition of the central veins before HD access. METHODS: This study comprised 30 consecutive patients (15 females, 15 males; age range 25-66 yrs, mean +/- SD 51.2 +/- 9.9 yrs). Of 30 patients, 26 had native AV fistulas and the remaining four patients, who had a history of previous subclavian vein catheterization, were candidates for HD fistulas. Nine patients had a radiocephalic fistula, 15 had a brachiobasilic fistula, one had a saphenous vein graft, and one had brachiobasilic vein transposition. To observe the fistula complications in these cases, three-dimensional (3-D) CE-MRA using gadolinium was performed. RESULTS: The results were considered normal in three patients (10%), who were candidates for AV fistula construction; one patient had central vein occlusion due to previous catheterization. Thirteen patients (43.3%) had venous stenosis or occlusion; three of them (10%) had low CE arteries distal to fistula region, leading to ischemic complications, and six (20%) had stenosis at the fistula region. Seven patients (23.3%) had venous pseudoaneurysms, whereas two of them had both pseudoaneurysms and fistula region stenosis, and one had both venous stenosis and pseudoaneurysm. There were no adverse or allergic-like reactions or heat and taste sensations observed in our series. CONCLUSIONS: 3-D CE-MRA is a useful, safe and a practical imaging modality in complicated fistula diagnosis with fewer complications and side-effects in comparison to fistulography.     

Combined endovascular stent grafting and endoscopic injection of fibrin sealant for aortoenteric fistula complicating esophagectomy

A 67-year-old man with previous total gastrectomy and roux-en-Y esophagojejunostomy had hematemesis 4 weeks after esophagectomy performed because of carcinoma of the esophagus. Investigation showed an aortojejunal fistula with a thoracic aortic pseudoaneurysm. Endovascular stent grafting of the pseudoaneurysm, followed by endoscopic injection of fibrin sealant for the fistula, was performed, and the infection was controlled with broad-spectrum antibiotic agents together with drainage and daily irrigation of the pseudoaneurysm sac. The fistula subsequently healed. The patient remained well 14 months after the procedure; follow-up computed tomograms at 12 months did not show any pseudoaneurysm, and there was no evidence of reopening of the fistula.     

Successful endovascular treatment for gastroduodenal artery pseudoaneurysm with an arteriovenous fistula after pancreas transplantation

The aim of this study was to demonstrate the usefulness of endovascular treatment for gastroduodenal artery pseudoaneurysm with an arteriovenous fistula after simultaneous pancreas–kidney transplantation. We describe the case of a 38-year-old man who underwent successful simultaneous pancreas–kidney transplantation. An asymptomatic pseudoaneurysm of the donor gastroduodenal artery with an arteriovenous fistula was incidentally diagnosed by routine color flow Doppler ultrasound (CDU) examination and confirmed by 3-D gadolinium-enhanced magnetic resonance angiography (MRA) 15 days after transplantation. Selective arteriography (via the right femoral artery) confirmed an arteriovenous fistula and a pseudoaneurysm of the donor gastroduodenal artery. The patient underwent successful endovascular embolization. At 11 months of follow-up, normal pancreatic function was reported. Endovascular treatment for gastroduodenal artery pseudoaneurysm with an arteriovenous fistula after pancreas transplantation obviates the need for surgical intervention.     

Color Doppler ultrasound for detection of renal arteriovenous fistulas

OBJECTIVES: Renal arteriovenous (AV) fistula is uncommon, but sometimes causes severe hematuria. To assess the value of color Doppler ultrasound (CD-US) for the detection of renal AV fistula, we retrospectively reviewed our experience with this disease. MATERIALS AND METHODS: Between 1994 and 2001, five patients with renal AV fistula were diagnosed in our institution. Post-biopsy AV fistula of the transplanted kidney was found in 1 patient. Renal AV fistula was detected in 2 patients who presented with gross hematuria. In the remaining 2 patients, renal AV fistula was discovered incidentally during abdominal ultrasonography. We evaluated gray-scale and CD-US imaging in those five patients. RESULTS: In all 5 patients, CD-US showed a whirling flow pattern within an echo-free structure suggesting AV fistula. However, it was difficult to distinguish AV fistula from aneurysm using only CD-US. While pulsed spectral Doppler evaluation of the lesion might be helpful, prompt venous filling on dynamic CT scan and/or renal arteriography was the most definitive sign for diagnosing the renal AV fistula. CONCLUSIONS: CD-US is excellent for demonstrating turbulent blood flow signals within the kidney. However, another radiographic study is required to give a definite diagnosis of renal AV fistula. Due to its low cost, low risk and wide availability, we recommend that CD-US be the first-line imaging procedure for the evaluation of hematuria and renal cystic lesion as well as for followup for renal AV fistula.     

Cerebral arteriovenous malformations, steal, and the hypertensive breakthrough threshold. An experimental study in rats

An experiment was designed to investigate the effects of arteriovenous (AV) fistula occlusion on cerebral autoregulation. A right carotid-jugular fistula was created in 63 rats in such a way as to produce an intracranial AV fistula with a loop extension into the neck. The fistula was occluded after an 8-week interval with the rats under both normotension and metaraminol-induced hypertension, and evidence of blood-brain barrier disruption was investigated with an Evans blue dye technique. The results indicate that an intracranial AV fistula may cause cerebral steal which is responsible for a reduction in the threshold for hypertensive breakthrough following fistula occlusion.     

Endovascular exclusion of iliac artery to iliac vein fistula after lumbar disk surgery

Iliac arteriovenous (AV) fistula is rare after lumbar disk surgery. Traditionally, open repair through the arterial lumen was performed. We report endovascular exclusion of an iliac AV fistula in a 41-year-old woman 8 years after lumbar diskectomy. An angiogram showed an AV fistula connecting the right common iliac artery and vein. This was repaired with placement of two covered wall stents in the right common artery and external iliac artery, and embolization of the right internal iliac artery. Contrast medium-enhanced computed tomography scan at 5 months confirmed elimination of the AV fistula and right iliac artery patency. This technique should be considered in management of iliac AV fistulas.     

Endovascular treatment of an iatrogenic large vessel arteriovenous fistula presenting as high output heart failure: a case report

Formation of an iatrogenic chronic large vessel arteriovenous (AV) fistula is an uncommon, early or late complication of spine surgery and associated with serious consequences. Its diagnosis is often delayed for months or years after the occurrence and rarely only after the patient develops heart failure secondary to a mature AV fistula. We present the case of a 43-year-old man with high-output heart failure due to an iatrogenic large vessel AV fistula after lumbar disc surgery successfully treated with the endovascular technique.     

Traumatic superior mesenteric arteriovenous fistula and aortic pseudoaneurysm 20 years after repair

A case of traumatic superior mesenteric arteriovenous fistula (SMAVF) and aortic pseudoaneurysm successfully treated by a unique combination of operative and endovascular techniques with a 20-year follow-up is reviewed. After 20 years, the patient presented with an aortoenteric fistula, which was managed with a cryopreserved aortic interposition graft. In this report, we review the evolution of the treatment for traumatic SMAVF and aortic pseudoaneurysm and the current management of aortoenteric fistula.     

Arteriovenous fistula after biopsy of renal transplant kidney: diagnosis and treatment

An 11-year-old renal transplant recipient was noted to have a bruit over her transplant graft 26 months post transplant and 17 months following percutaneous renal biopsy during an episode of rejection. Diagnosis of an arteriovenous (AV) fistula was made by ultrasound examination with Doppler flow and was confirmed with arteriography. The AV fistula was occluded by transcatheter embolotherapy with placement of a steel coil into the fistula from the renal vein approach. This procedure allowed nonsurgical closure of the AV shunt without significant change in renal function.