Spinal ventral epidural arteriovenous fistulas of the lumbar spine: angioarchitecture and endovascular treatment

Introduction

Spinal ventral epidural arteriovenous fistulas (EDAVFs) are relatively rare spinal vascular lesions. We investigated the angioarchitecture of spinal ventral EDAVFs and show the results of endovascular treatment.

Methods

We reviewed six consecutive patients (four males and two females; mean age, 67.3 years) with spinal ventral EDAVFs treated at our institutions from May 2011 to October 2012. All patients presented with progressive myelopathy. The findings of angiography, including 3D/2D reformatted images, treatments, and outcomes, were investigated. A literature review focused on the angioarchitecture and treatment of spinal ventral EDAVFs is also presented.

Results

The EDAVFs were located in the ventral epidural space at the L1–L5 levels. All EDAVFs were supplied by the dorsal somatic branches from multiple segmental arteries. The ventral somatic branches and the radiculomeningeal arteries also supplied the AVFs in two patients. The AVFs drained via an epidural venous pouch into the perimedullary vein in four patients and into both the perimedullary vein and paravertebral veins in two patients. Four cases without paravertebral drainage were treated by transarterial embolization with diluted glue, and two cases with perimedullary and paravertebral drainages were treated by transvenous embolization alone or in combination with transarterial embolization. An angiographic cure was obtained in all patients. Clinical symptoms resolved in two patients, markedly improved in three patients, and minimally improved in one patient.

Conclusion

In our limited experience, spinal ventral EDAVFs were primarily fed by somatic branches. EDAVFs can be successfully treated by endovascular techniques selected based on the drainage type of the AVF.     

Giant serpentine aneurysms: radiographic features and endovascular treatment.

PURPOSETo describe the characteristic CT, MR, and angiographic features of giant serpentine aneurysms and discuss their endovascular treatment.METHODSThirteen patients with giant serpentine aneurysms were studied at our institution in the last 3 years. They all underwent CT and MR studies as well as cerebral angiography. More recently, some of the patients were studied with MR angiography. Seven patients had endovascular occlusion of the giant serpentine aneurysms, 3 with N-butyl cyanoacrylate, 2 with Guglielmi detachable coils, and 2 with detachable balloons.RESULTSGiant serpentine aneurysms mimic cerebral neoplasms on CT and MR studies; they are often associated with mass effect and adjacent edema, and they enhance with contrast medium. The cerebral angiogram shows a residual irregular lumen of the partially clotted aneurysm, which continues into normal branches supplying the distal arterial territory. Six patients were treated successfully with an endovascular approach consisting of complete and permanent occlusion of the parent artery.CONCLUSIONGiant serpentine aneurysms from a subgroup of large intracranial aneurysms that have specific CT, MR, and angiographic features, which should be recognized before their treatment. The endovascular treatment of the aneurysm consists of permanent occlusion of the parent artery.     

Giant spinal perimedullary fistula in hereditary haemorrhagic telangiectasia: diagnosis,endovascular treatment and review of the literature

Hereditary hemorrhagic telangiectasia (HHT, Rendu-Osler-Weber disease) is a vascular disorder with dominant autosomal transmission characterised usually by multiple mucocutaneous and visceral abnormalities. Neurological manifestations due to the primary involvement of spinal cord by vascular malformations are rare. We present a young man with HHT associated with a central nervous system arteriovenous malformation and a giant perimedullary fistula, that was manifested as progressive myelopathy. The diagnosis was made coupling magnetic resonance imaging to selective spinal arteriography. The therapeutic option was endovascular treatment by mechanically detachable coils which resulted in full exclusion of the fistula with full improvement of symptoms. During follow-up a stable clinical and morphological outcome was achieved. Clinical manifestations in HHT, with emphasis on neurological symptoms, are reviewed as well as the therapeutic options to deal with giant perimedullary fistula.     

Multiple dural arteriovenous fistulas of the cranium and spine

Dural arteriovenous fistulas are acquired lesions that usually involve the dura around the cavernous sinus. The transverse, sigmoid, and superior sagittal sinuses may be affected occasionally. With the exception of bilateral cavernous sinus dural arteriovenous fistulas, the simultaneous occurrence of dural arteriovenous fistulas at two locations is rare. Among 105 patients evaluated for dural arteriovenous fistulas, we identified seven patients with fistulas at two sites. The age of the patients ranged from 27 to 74 years. Presentation was related to hemorrhage in three patients, loss of vision in four, and a bruit and headaches in one. Patients were treated with combined surgical and endovascular techniques. All treated lesions were completely closed with no mortality or permanent morbidity. The presence of multiple fistulas must be considered in patients being evaluated for dural arteriovenous fistulas. Patients with multiple fistulas usually present with life-threatening hemorrhages or acute neurologic decline; the risk factor for hemorrhages, including those related to venous outflow obstruction, is high in patients with multiple dural arteriovenous fistulas.     

Superior cerebellar artery infarction in endovascular treatment for tentorial dural arteriovenous fistulas

Background

Superior cerebellar artery (SCA) syndrome shows ipsilateral cerebellar ataxia and Horner's syndrome, contralateral superficial sensory disturbance, as well as nystagmus toward the impaired side, vertigo, and nausea. Occasionally, unilateral lesions may produce bilateral hypogeusia and contralateral hypoacusia.

Objective

To report 2 patients with unilateral lower midbrain ischemic lesions of the inferior colliculus level caused by transarterial embolization for tentorial dural arteriovenous fistulas (TDAVFs).

Methods

Hospital records for 21 patients with TDAVFs mainly treated by endovascular techniques between 2005 and 2008 were reviewed. Two patients with MRI evidence of unilateral SCA territory infarction were investigated.

Results

Of 21 patients, 2 treated transarterially with Onyx-18 (a nonahesive liquid embolic agent) developed infarctions in the territory of SCA. One patient had lateral SCA infarction characterized by ipsilateral gait ataxia, contralateral hemihypoesthesia, with additional ipsilateral ocular motor palsy and bilateral gustatory loss. And the other patient had medial SCA infarction characterized by ipsilateral ataxia contralateral hemihypoesthesia with additional contralateral hypoacusia.

Conclusion

SCA infarction can be caused by transarterial injection of Onyx-18 via SCA or the posterior cerebral artery (PCA) for TDAVFs and additionally presented with gustatory loss and deafness, which is generally not a feature of the SCA syndrome.     

Endovascular treatment of high-risk tentorial dural arteriovenous fistulas: clinical outcomes

Introduction  An increasing number of intracranial dural arteriovenous fistulas (DAVFs) are amenable to endovascular treatment with Onyx-18. We reviewed our experience with the endovascular management of tentorial dural arteriovenous fistulas (TDAVFs) treated transarterially and transvenously. Materials and methods  Clinical records for 19 consecutive patients (three women, 16 men) with TDAVFs treated endovascularly between 2005 and 2008 were reviewed to determine their presenting symptoms, angiographic features, endovascular treatments, and clinical outcomes. Most patients (78.9%) presented with intracranial hemorrhage (ICH). All patients had high-risk angiographic features such as leptomeningeal venous varix. Results  Transarterial embolization was performed in 19 patients. Transvenous embolization was additionally performed in two patients and caused one death. At the time of the last follow-up evaluation, 16 (84.2%) patients had good or excellent outcomes (modified Rankin score, 0 or 1) and one (5.3%) was deceased. Six patients had a residual fistula and were treated with gamma knife radiosurgery. The overall morbidity and mortality rate was 10.5%. Conclusion  High-risk TDAVFs can be successfully managed with good outcomes. When anatomic features can be accessed endovascularly, endovascular treatment is indicated. Patients with residual filling of the DAVF should be considered for adjuvant therapy, including further radiosurgery.     

Giant cholesterol cysts of the petrous apex: radiologic features

Four cysts are described that expanded and destroyed the bone of the petrous apex. All patients with these cysts had a sensorineural hearing loss. Mild symptoms referable to cranial nerves VI, VII, IX, X, XI, and XII were seen also. The cysts range in size from 1.5 X 1.5 X 3 cm to 5 X 5 X 6 cm. Grossly and histologically, they were distinct from any lesions seen previously. The lesions were large and contained glistening brown, watery fluid filled with cholesterol crystals. The cyst wall was predominantly fibrous tissue without an epithelium. Minimal chronic inflammatory change and granuloma formation were present within and just outside the cyst wall. These cysts have been described as mastoid cysts, epidermoids, mucoceles, and cholesterol granulomas; until now, they have not been recognized as a single distinct entity. A name emphasizing the pathologic characteristic of the lesion, giant cholesterol cyst, has been suggested. Distinguishing them from other petrous apex lesions preoperatively is difficult, but if the cystic nature of the lesion can be recognized or at least anticipated, more conservative surgery, such as simple drainage versus a more radical procedure, may be possible.     

In vitro models of intracranial arteriovenous fistulas for the evaluation of new endovascular treatment materials

BACKGROUND AND PURPOSE: The purpose of this study was to create and test an in vitro model of intracranial arteriovenous fistulas (AVFs) that simulates the geometry of human vasculature and allows realistic testing of devices used in endovascular therapy. METHODS: The models were derived from corrosion casts of the main cervicocranial arteries and veins obtained from two nonfixed human specimens. Wax copies of the casts were produced and combined to create complex models simulating various types of intracranial AVFs. Wax assemblies were embedded with liquid silicone solidified into transparent blocks containing, after wax evacuation, hollow reproductions of the original vascular trees. The models were connected to a pulsatile pump and their compatibility with various imaging techniques and endovascular treatment materials was evaluated. RESULTS: The models were compatible with digital subtraction angiography, CT, MR imaging, and transcranial Doppler sonography. They provided a realistic endovascular environment for the simulation of interventional neuroradiologic procedures. CONCLUSION: Anatomically accurate and reproducible in vitro models of intracranial AVFs provide a valuable method for evaluating new endovascular treatment materials and for teaching purposes.     

Clinical and angiographic features of pulmonary arteriovenous fistulas in children.

Multiple pulmonary arteriovenous fistulas were demonstrated angiographically in 8 patients who exhibited cyanosis and polycythemia during childhood. Cyanosis was first observed during infancy in 5 patients. The diffuse (telangiectatic) type was present in 2 cases, while the remainder were of the multiple discrete type with one or two dominant fistulas. The clinical and angiographic features and surgical implications of multiple pulmonary arteriovenous fistulas in these children and those reported previously are discussed.     

肢体动静脉畸形的介入放射学诊断与治疗

目的探讨血管造影和动脉栓塞对肢体动静脉畸形的诊断、治疗价值。方法１１例肢体动静脉畸形行选择性动脉造影检查，对５例具有明显动静脉瘘的病人进行了１０次动脉栓塞治疗。栓塞时联合使用了包括鱼肝油酸钠在内的不同种类液态和固体栓塞材料。结果动脉造影明确了病变中静脉畸形和动静脉瘘何者为主，为分类和选择治疗方法提供了依据。２例栓塞后外科手术治疗，术中出血减少。３例单纯栓塞治疗的病变得到有效控制。结论动脉造影和栓塞是肢体动静脉畸形诊断治疗中的重要环节，鱼肝油酸钠可有效地用于动脉栓塞治疗肢体动静脉畸形     

Aortoenteric and paraprosthetic-enteric fistulas: radiologic findings.

Ten cases of graft-intestinal fistulas occurred in 712 patients who had undergone abdominal aortic reconstructive surgery. Radiographic abnormalities were demonstrated in eight--three by conventional barium gastrointestinal examinations and five by angiography. A high index of suspicion of the condition and an aggressive radiologic workup are recommended.     

Failing arteriovenous dialysis fistulas: evaluation and treatment

A total of 31 patients with 45 episodes of failing arteriovenous dialysis fistulas was studied. Fistula failure was usually due to venous and/or anastomotic stenosis, often in conjunction with thrombosis. Abnormalities were treated by percutaneous dilation and occasionally streptokinase infusion. Most complications and failures occurred either in patients with recently created fistulas or in those with multiple or long segment stenosis associated with thrombosis. Patients with a single nonobstructing stenosis were very successfully treated with percutaneous techniques, which are the treatment of choice for this condition.     

Experimental arteriovenous fistulas: treatment with silicone-covered metallic stents.

PURPOSETo determine the efficacy of silicone-covered metallic stents in the treatment of experimentally created carotid-jugular fistulas.METHODSCarotid-jugular fistulas were surgically constructed in six mongrel dogs. Silicone-coated, self-expanding metallic stents were placed across the fistula holes within the carotid artery, and carotid angiography was performed before, immediately after, and 4 and 8 weeks after stent placement. Fistula specimens were resected 2 months after stent placement and analyzed by means of gross and light microscopy.RESULTSAngiography revealed complete closure of all fistulas immediately after stent deployment. The fistulas remained closed and all carotid arteries remained patent. Marked stenosis within the carotid lumen was seen along the proximal and distal ends of the stents. Gross and micropathologic specimens of the carotid-jugular fistulas revealed fibrous connective tissue and collagen across the fistula holes. Proliferative fibrous connective tissue, collagen, and fibromyoblasts were located at either end of the stents. The wires of the stents indented the intraluminal surface of the carotid arteries.CONCLUSIONSSilicone-covered stents were effective in closing all experimentally created carotid-jugular fistulas. With further refinements and variations in technique, covered stents may prove a viable alternative to current endovascular devices.     

Arteriovenous fistulas of the lung--their clinical aspects and radiologic images

Based on the data of 15 patients the typical radiological signs of pulmonary arteriovenous fistulas, their differential diagnostic implications, clinical signs and symptoms and management are reviewed. In addition, lung function parameters of 9 patients are presented. The critical role of pulmonary angiography and sequential dynamic CT for the diagnosis is stressed, particularly in those cases in which conventional chest radiographs and tomographies fail to show characteristics abnormalities. Since pulmonary arteriovenous fistulas tend to increase in size and cause complications, they should be subjected to intermediate treatment, even if they are of no haemodynamic relevance.     

Intestinal anisakiasis: clinical and radiologic features

We report the clinical and radiologic features of 12 patients with acute intestinal anisakiasis. Diagnosis of anisakiasis was made immunologically by positive antibody to Anisakis larvae and a recent history of raw fish intake. Severe abdominal pain was a major symptom in these patients-half experienced fluid levels indicating ileus on plain x-ray films of the abdomen. Radiologic findings included irregular thickening of the jejunum, ileum, or colon, with mucosal edema and luminal narrowing with dilatation of the proximal intestine. In two cases a thread-like filling defect suggesting a worm was visualized on the x-ray film. These findings were interpreted as anisakiasis. Although ileus developed in some patients, all were treated and cured completely without surgery.     

Postcatheterization pseudoaneurysms and arteriovenous fistulas: repair with percutaneous implantation of endovascular covered stents

PURPOSE: To assess the effectiveness and safety of endovascular covered stents in the management of pseudoaneurysms and arteriovenous fistulas after cardiac and vascular catheterization. MATERIALS AND METHODS: Twenty-six endovascular covered stents were used to repair 16 pseudoaneurysms, nine arteriovenous fistulas, and one combined lesion after femoral arterial puncture for diagnostic coronary angiography and/or angioplasty. Fistulas and aneurysms were in the superficial femoral artery in 16 cases, in the deep femoral artery in six cases, and in the common femoral artery in four cases. Implantation was performed from the opposite femoral artery in most cases. It was not possible to treat three additional cases transcutaneously for technical reasons (three of 29 cases). RESULTS: Percutaneous closure of the lesions with an endovascular covered stent was successful in 26 of 29 cases. Initial follow-up showed good stent patency. Two major complications were observed after stent implantation. During follow-up (about 1 year in 23 of 26 patients [88%]), stent thromboses were detected in four of 23 patients (17%) with follow-up color duplex flow imaging. CONCLUSION: Implantation of endovascular covered stents is an effective and safe method for the percutaneous closure of pseudoaneurysms and arteriovenous fistulas. Thus, endoluminal vascular repair with covered stents offers an alternative therapeutic approach to vascular surgery in selected patients.     

Treatment of slow-flow (type I) perimedullary spinal arteriovenous fistulas with special reference to embolization

Embolization of type I perimedullary spinal arteriovenous fistulas (AVFs) can be difficult, because of tortuosity and the small diameter of the feeder and distal location of the fistula site. The 1.5F flow-directed catheter in conjunction with a hydrophilic guidewire has been used in fistula embolization with cyanoacrylate glue for spinal vascular malformations at our institution. This combination has improved our success rate in achieving superselective catheterization of the fistula. Thus, 4 of 5 patients with type I perimedullary AVFs could be cured with this technique. Like type II and type III perimedullary AVFs, the endovascular approach may also be the first line of treatment in type I perimedullary spinal AVF.     

覆膜血管内支架在外周动脉瘤和动静脉瘘中的应用

目的探讨覆膜血管内支架在外周动脉瘤及动静脉瘘中的临床应用疗效及安全性。方法回顾性分析我院2000年5月至2006年11月14例接受覆膜血管内支架治疗患者的临床资料。14例患者主要的血管病变为真性或假性动脉瘤、动静脉瘘。结果覆膜血管内支架的置放技术成功率为100%,无严重并发症和围手术期死亡,术后临床症状明显改善。1例患者出现I型内漏,但临床症状仍有改善。平均随访时间10个月。随访期内除1例患者仍有内漏外余无内漏。未发现支架移位和狭窄等并发症。结论覆膜血管内支架治疗外周动脉瘤及动静脉瘘具有创伤小、疗效确切、安全等优点,短期随访效果满意。     

High-flow,small-hole arteriovenous fistulas: treatment with electrodetachable coils.

We present one case of carotid-cavernous fistula caused by percutaneous treatment of trigeminal neuralgia and one case of vertebrovertebral fistula caused by percutaneous internal jugular vein cannulation. Each fistula had a small arteriovenous communication that prevented the use of detachable balloons. Endovascular transarterial treatment of these two iatrogenic fistulas with electrically detachable platinum coils was performed. Both fistulas were occluded with preservation of the parent artery, and the patients have fully recovered.