Fistulous Connection Research Articles

768. ENDOSCOPIC MANAGEMENT OF COMPLEX THORACIC AORTA ANEURYSMAL SAC AND ENDOGRAFT INFECTION ASSOCIATED WITH AORTOESOPHAGEAL FISTULA

Abstract Background Aortoesophageal fistula (AEF) is a rare but life-threatening condition. Secondary AEF is a complex pathology occurring after thoracic aorta surgery with prosthetic graft, with an incidence of 1.6%. However, this is likely to rise with the increasing number of thoracic endovascular aortic repair (TEVAR) being performed. Management of secondary AEF is more challenging due to presence of adhesions in the pleural space, co-existing endograft infection and poor physiology of this group of patients. Definitive surgery carries high mortality rate and not all patients are suitable candidates. We review a case of secondary AEF with thoracic endograft infection managed non-operatively. Methods Our patient is a 70 years old man with a background of Stanford type A aortic dissection managed with ascending aorta and hemi-arch replacement with Dacron graft. Six years later, he had frozen elephant trunk reconstruction due to aneurysmal dilatation. Three months later, he underwent TEVAR for descending thoracic aorta aneurysm. Post-operation, he was diagnosed with Flavonifractor plautii bactaeremia secondary to infected aneurysmal sac and aortic stent graft and was initiated on antimicrobial therapy. During this time patient also developed recurrent episodes of haemoptysis. Bronchoscopy excluded an aortobronchial fistula and Oesophago-gastro-duodenoscopy (OGD) confirmed AEF at 25 cm from incisors. Results After discussion with a multidisciplinary team and patient, endoscopic management was chosen over surgery. Initial endoscopic closure of AEF with over-the-scope-clip appeared satisfactory but repeat OGD showed recurrence of new AEF which was partially closed with clips. Repeat imaging showed worsening mediastinal infection with larger gas-containing cavity. OGD was repeated with contrast demonstrating fistulous connection between the oesophagus and aneurysmal sac. A 7-French 4 cm double pigtail (DPT) stent was deployed into the sac under fluoroscopy to allow for trans-oesophageal drainage. Repeat imaging showed improvement in infection (Figure 1). Patient underwent endoscopic exchange of DPT stent 2 months after the initial insertion. Conclusion Definitive surgery for secondary AEF includes drainage of infection, explantation of infected endograft and aortic and oesophageal reconstruction. Oesophagectomy is preferred over primary repair of oesophageal defect. Not all patients will be suitable candidates for radical surgery and a non-operative approach may be required. Our patient likely has dense pleural and mediastinal adhesions from previous surgeries and thus, repeat surgery will be more challenging with increased risk of complications. However, if his mediastinal infection fails to resolve despite a period of DPT stent drainage, definitive surgery involving McKeown minimally invasive oesophagectomy with substernal gastric pull up would be required. Figure 1: Image A shows a large cavity with air and coalescent locules (arrow) prior to insertion of DPT stent. Image B shows a collapsed cavity (arrow) after DPT stent insertion.

Percutaneous Closure of Fistulous Tract from Right Coronary Artery to Right Atrium: A Case Report

The coronary artery fistula is a rare form of left to right shunt that can lead to significant hemodynamic consequences if left untreated. The patient, a 10-year-old female, presented with symptoms of increasing dyspnea and palpitations over the past year. Diagnostic imaging, including transthoracic echocardiography and cardiac computed axial tomography, confirmed the presence of a fistulous connection between the right coronary artery and the right atrium. Given the patient’s symptomatic presentation and the risk of complications, a decision was made to proceed with percutaneous closure. Using a catheter-based approach, the fistula was successfully occluded with a Amplatzer Vascular Plug II (AVP II), resulting in the resolution of symptoms and normalization of hemodynamic parameters. This case highlights the efficacy and safety of percutaneous intervention in managing coronary artery fistulas, particularly in pediatric patients, and underscores the importance of early diagnosis and treatment to prevent long-term sequelae.

Bronchoscopic management in persistent air leak: a narrative review.

Persistent air leak (PAL) represents a challenging medical condition characterized by prolonged air leak from the lung parenchyma into the pleural cavity, often associated with alveolar-pleural fistula or bronchopleural fistula (BPF). The objective of this narrative review is to explore the causes, clinical implications, and the evolving landscape of bronchoscopic treatment options for PAL. The literature search for this review was conducted using databases such as PubMed/MEDLINE, and Scopus databases. Articles published from inception until 28th August, 2023, focusing on studies that discussed the causes, diagnosis, and management strategies for PAL were included. Keywords included bronchoscopic management, bronchopleural fistula, endobronchial valve, sealant, blood patch pleurodesis, spigot, air leak, PAL, management, comparative study. PAL commonly arises from secondary spontaneous pneumothorax, necrotizing pneumonia, barotrauma induced by mechanical ventilation, chest trauma, or postoperative complications. Understanding the underlying etiology is crucial for tailoring effective management strategies. While conventional intercostal drainage resolves the majority of pneumothorax cases, PAL is diagnosed when the air leak persists beyond 5 to 7 days. Prolonged PAL can lead to worsening pneumothorax, respiratory distress, and increased morbidity. Early identification and intervention are essential to prevent complications. Conservative approaches involve close monitoring and supplemental oxygen therapy. These strategies aim to promote natural healing and resolution of the air leak without invasive interventions. Bronchoscopic techniques, such as endobronchial valves (EBVs), sealants, and autologous blood patch (ABP), have emerged as promising alternatives for refractory PAL. These interventions offer a targeted and minimally invasive approach to seal the fistulous connection, promoting faster recovery and reducing the need for surgical interventions. PAL is a clinical challenge, and their management requires a tailored approach based on the underlying cause and severity. Bronchoscopic interventions have shown efficacy in cases of refractory PAL. Early recognition, multidisciplinary collaboration, and a personalized treatment plan are essential for optimizing outcomes in patients with PAL.

Step-by-step venous navigation in treatment of tentorial dural arteriovenous fistula supplied by artery of Bernasconi and Cassinari.

The artery of Bernasconi and Cassinari is a small infraclinoid branch of the internal carotid artery that originates from its cavernous segment and then runs along the tentorium. Because of its gracile appearance, it is often visible only when related to neoplasms and vascular lesions in the tentorial regions.1 Dural arteriovenous fistulas (dAVFs) are arteriovenous shunts contained within the dural leaflets, supplied largely by the regional meningeal arteries and classified based on the type of venous drainage. Tentorial dAVFs are mostly supplied by branches of the meningohypophyseal trunk, including the artery of Bernasconi and Cassinari.2 Unlike fistulas of other locations, tentorial fistulas are linked with a higher risk for venous hypertension and hemorrhage and thus demand immediate and appropriate treatment.3 Digital subtraction angiography is necessary to understand its arterial and venous components. Treatment aims to achieve complete embolization of the fistulous connection and venous portions by either a transarterial or transvenous approach, without causing serious changes in the flow dynamics.4, 5.

Diagnosis and Management of Congenital Coronary Artery Fistulas in Adults.

This review describes the presentation, diagnosis, and management of congenital coronary artery fistulas (CAFs) in adults. CAFs are classified as coronary-cameral or coronary arteriovenous fistulas. Fistulous connections at the distal coronary bed are more likely to be aneurysmal with higher risk of thrombosis and myocardial infarction (MI). Medium-to-large or symptomatic CAFs can manifest as ischemia, heart failure, and arrhythmias. CAF closure is recommended when there are attributable symptoms or evidence of adverse coronary remodeling. Closure is usually achievable using transcatheter techniques, though large fistulas may require surgical ligation with bypass. Given their anatomic complexity, cardiac CT with multiplanar 3-D reconstruction can enhance procedural planning of CAF closure. Antiplatelet and anticoagulation are essential therapies in CAF management. CAFs are rare cardiac anomalies with variable presentations and complex anatomy. CAF management strategies include indefinite medical therapy, percutaneous or surgical CAF closure, and lifelong patient surveillance.

Transvenous embolization of noncavernous dural arteriovenous fistulas (dAVFs): A systematic review and meta-analysis.

Intracranial dural arteriovenous fistulas (dAVFs) are abnormal connections between arteries and veins within the dura mater. Various treatment modalities, such as surgical ligation, endovascular intervention, and radiosurgery, aim to close the fistulous connection. Although transvenous embolization (TVE) is the preferred method for carotid-cavernous fistulas, its description and outcomes for noncavernous dAVFs vary. This has prompted a systematic review and meta-analysis to comprehensively assess the effectiveness of TVE in treating noncavernous dAVFs, addressing variations in outcomes and techniques. We searched PubMed and Embase, spanning from the earliest records to December 2022, to identify pertinent English-language articles detailing the utilization of TVE. We focused on specific procedural details, outcomes, and complications in patients older than 18 years. The data collected and analyzed comprised the sample size, number of fistulas, publication specifics, presenting symptoms, fistula grades, and pooled rates of embolizations, outcomes, follow-up information, and complications. From a total of 565 screened articles, 15 retrospective articles encompassing 166 patients spanning across seven countries met the inclusion criteria. Their Newcastle-Ottawa scores ranged from 6 to 8. Intraprocedural complication rate was 10% (95% confidence interval [CI] = 5.9-17.1) and in-hospital postprocedural complication rate was 5.4% (95% CI = 2.8-10.6). Prevalence of in-hospital mortality was 5.5% (95% CI = 2.9-10.6). Complication rate during follow-up was 8.6% (95% CI = 4.7-15.7) with fistula rupture occurring in 5.5% (95% CI = 2.6-11.6) of patients. Complete obliteration rate at final angiographic follow-up was 94.9% (95% CI = 90.3-99.9). Symptoms improved in 95% (95% CI = 89.8-100) of patients at final follow-up. To our knowledge, we present the first meta-analysis assessing obliteration rates, outcomes, and complications of TVE for dAVFs. Our analysis highlights the higher (>90%) complete obliteration rates. Large prospective multicenter studies are needed to better define the utility of TVE for noncavernous dAVFs.

Pulmonary AVM Embolization

Pulmonary arteriovenous malformations (PAVMs) are rare fistulous connections between pulmonary arteries and veins that, as in our case, are commonly associated with hereditary hemorrhagic telangiectasia (HHT). Embolotherapy, the mainstay of treatment for PAVMs, is a procedure in which the feeding arteries of a malformation are endovascularly occluded under fluoroscopic guidance. Effective and well-tolerated, embolotherapy has been shown to decrease right-to-left shunting following treatment and decrease risks of paradoxical embolization and lung hemorrhage and to improve pulmonary gas exchange and lung function. Patients are selected for treatment according to clinical suspicion for the presence of a PAVM and feeding artery diameter. The occlusion of PAVMs with arteries that exceed 2-3 mm in diameter is recommended. Diagnostic contrast-enhanced pulmonary angiography is performed via injection of contrast through a percutaneous catheter to characterize and confirm PAVMs suitable for embolization. Lesions are then treated by catheter-directed placement of embolic material— vascular plugs in our case—into the feeding artery, terminating blood flow to the area of the lesion. Although multiple PAVMs may be embolized during a single session, in patients with HHT, who may present with large numbers of PAVMs, treatment is limited by maximum contrast dosage, and additional sessions may be performed if PAVMs remain perfused.

Fractal-Based Analysis of Arteriovenous Malformations (AVMs).

Arteriovenous malformations (AVMs) are cerebrovascular lesions consisting of a pathologic tangle of the vessels characterized by a core termed the nidus, which is the "nest" where the fistulous connections occur. AVMs can cause headache, stroke, and/or seizures. Their treatment can be challenging requiring surgery, endovascular embolization, and/or radiosurgery as well. AVMs' morphology varies greatly among patients, and there is still a lack of standardization of angioarchitectural parameters, which can be used as morphometric parameters as well as potential clinical biomarkers (e.g., related to prognosis).In search of new diagnostic and prognostic neuroimaging biomarkers of AVMs, computational fractal-based models have been proposed for describing and quantifying the angioarchitecture of the nidus. In fact, the fractal dimension (FD) can be used to quantify AVMs' branching pattern. Higher FD values are related to AVMs characterized by an increased number and tortuosity of the intranidal vessels or to an increasing angioarchitectural complexity as a whole. Moreover, FD has been investigated in relation to the outcome after Gamma Knife radiosurgery, and an inverse relationship between FD and AVM obliteration was found.Taken altogether, FD is able to quantify in a single and objective value what neuroradiologists describe in qualitative and/or semiquantitative way, thus confirming FD as a reliable morphometric neuroimaging biomarker of AVMs and as a potential surrogate imaging biomarker. Moreover, computational fractal-based techniques are under investigation for the automatic segmentation and extraction of the edges of the nidus in neuroimaging, which can be relevant for surgery and/or radiosurgery planning.

Veno-Venous Coiling as A Strategy to Wean Extracorporeal Membrane Oxygenator Post Adult Fontan Completion

We discuss a case of veno-venous collaterals in a patient with Fontan circulation post complex redo-surgery, which impeded veno-venous extracorporeal membrane oxygenation (VV-ECMO) weaning. A 31-year-old male, born with complex congenital heart disease (D-transposition of the great vessels, tricuspid atresia, aortic coarctation, ventricular septal defect, and hypoplastic right ventricle) with single ventricle physiology. The patient underwent multiple cardiac surgeries leading to Fontan completion. He subsequently developed significant aortic regurgitation with progressive left ventricular dilatation requiring multiple readmissions for congestive heart failure. Despite maximal medical optimisation he remained symptomatic and was offered further surgery. Complex 6th redo-operation with aortic valve replacement, modification to intracardiac fenestrated Fontan and insertion of intra-aortic balloon pump was performed. At 72 hours postoperative, VV-ECMO was required for refractory hypoxia. Right heart catheterisation was performed with coiling of two large fistulous venous connections. Post-coiling saturations improved from 92% to 98%. The patient was successfully weaned from VV-ECMO and decannulated the following day. This case demonstrates successful embolisation for veno-venous collaterals causing significant right to left shunt and hypoxia, in a patient with Fontan circulation.

Abstract 016: Endovascular Coiling of a Left L3 Radicular Artery Mycotic Aneurysm

Introduction Mycotic aneurysms of paraspinal arteries are a rare finding. The most commonly affected vessels include the aorta, iliac, visceral, femoral, brachial, and cerebral arteries, often occurring in the setting of bacteremia, direct invasion from local infection, septic emboli from infective endocarditis, or arterial trauma.¹⁻³ However, there is limited existing documentation of mycotic aneurysms of the spinal vasculature.² Furthermore, knowledge regarding the management of paraspinal mycotic aneurysms and the efficacy of endovascular repair of these lesions is scarce.⁴ Methods We present a 51‐year‐old male with a past medical history of diabetes mellitus, end‐stage renal disease on hemodialysis (T/T/S), hypertension, congestive heart failure, peripheral arterial disease s/p right bilateral knee amputation, coronary artery disease, and epilepsy that presented with a 2‐week duration of severe low back pain with associated left upper and lower extremity numbness, subjective fevers, generalized weakness, diffuse abdominal pain, nausea and vomiting. Neurological exam on admission was remarkable for left lower extremity paresthesia of no clear dermatomal distribution with no other focal deficits. CT of the abdomen and pelvis revealed concern for L3‐L4 discitis and osteomyelitis and a greater than 3 cm homogeneously enhancing lesion within the paraspinal muscles of the same level concerning for neoplasm vs. vascular malformation vs. pseudoaneurysm (Figure 1A). An emergent MRI lumbar spine revealed a left L3 radicular artery saccular aneurysm concerning for a mycotic aneurysm in the setting of infection (Figure 1B). Results Patient underwent cerebral and spinal angiography which showed a left L3 radicular artery ruptured mycotic aneurysm measuring 11.26 x 6.5 mm in mediolateral and craniocaudal diameters associated with a 16.4 x 21 mm pseudoaneurysm (Figure 1C). Successful coiling of the aneurysm, pseudoaneurysm, and fistulous connection were performed with Penumbra 400 coils and PAC coils. There was no opacification of the aneurysms at the end of the procedure and no procedural complications (Figure 1D). CT‐guided biopsy of the L3‐L4 disc was also obtained. Postoperatively, the patient was hypertensive to a systolic blood pressure of 220 mmHg that was controlled with a nicardipine infusion that was gradually weaned off once the patient’s vitals were stable while in the Neuro‐ICU. The patient’s discitis and osteomyelitis were identified as the source of infection for the aneurysm and managed medically with IV antibiotics and analgesics with no need for any acute neurosurgical intervention. Blood cultures showed no growth throughout admission and biopsy of lumbar vertebrae showed normal skin flora. Patient with stable neurological exam throughout his stay. Patient was transferred to the floor before ultimately discharging home per patient preference. Conclusion Endovascular embolization is a potentially efficacious therapy for the management of mycotic aneurysms of the spinal vasculature. Endovascular repair has been demonstrated as a surgical option for mycotic aneurysms in other vessels, such as the aorta, but further research and replication are needed to establish the utility of coiling in the setting of paraspinal mycotic aneurysms.⁵⁻⁷

Congenital Hepatic Arteriovenous Malformation: Often Missed Cause for Neonatal Pulmonary Arterial Hypertension

Congenital hepatic arteriovenous malformations (AVM) are extremely rare, with an incidence of less than 1 in 1 hundred thousand, and the literature is limited to only a few case reports. They are characterised by an abnormal arterial connection to a fistulous venous connection within the liver. This results in high flow, low resistance circulation that causes high output cardiac failure. We report a late-preterm male newborn who presented with respiratory distress and signs of cardiac failure on day 1 of life. The newborn is diagnosed with hepatic AVM as the cause of severe pulmonary arterial hypertension (PAH) and cardiac failure. This case report, along with the literature review, emphasises the need for a high index of suspicion to look for hepatic AVM in a newborn presenting with unexplained PAH and cardiac failure and also discusses different management strategies for hepatic AVM.

A Rare Case of Left Anterior Descending Coronary Artery to Pulmonary Trunk Fistula Associated with Takotsubo Cardiomyopathy.

Coronary-artery-to-pulmonary-artery fistulae represent rare vascular anomalies defined as abnormal communications between the coronary arteries and the pulmonary arterial system. Takotsubo Syndrome represents a stress-induced cardiomyopathy defined by transient regional systolic dysfunction of the left ventricle, with minimal elevation of cardiac biomarkers, without angiographic evidence of obstructive coronary artery disease. We hereby richly illustrate an unusual and rare case of a female patient with Takotsubo Cardiomyopathy and left-anterior-descending-coronary-artery-to-pulmonary-trunk fistula through multi-modality imaging evaluations, obtaining a detailed anatomical representation of the coronary arteries and the fistulous connection, which further guided the optimal treatment strategy. The patient was treated conservatively. The main teaching points of this case are the following: (1) The coronary fistula may represent just an incidental finding in a Takotsubo Cardiomyopathy clinical scenario. (2) The particularly rare association between left-anterior-descending-coronary-artery-to-pulmonary-trunk fistula and Takotsubo Cardiomyopathy presentation is mainly due to the stress-induced overstimulation of myocardial beta-1 receptors, accentuating the coronary steal phenomenon in the setting of the coronary fistula, manifesting as anginal pain, and also the stress-induced adrenergic drive causing the Takotsubo-like presentation with apical ballooning of the left ventricle.

A rare case of pulmonary artery to left atrium fistula

BackgroundThe first description of right pulmonary artery-to left atrium communication was done by Friedlich and coauthors in 1950. The right pulmonary artery and left atrium are directly connected by the right pulmonary artery to left atrial fistula through a thin-walled aneurysm. Here, we describe a female adult patient who underwent investigation for dyspnea and had Type 1 right pulmonary artery to left atrium connection.Case presentationTwenty-two-year-old female presented with history of breathlessness (New York Heart association classification grade III) for 3 years. On initial examination, her saturation was 60% with no clinical evidence of cyanosis. Initial radiographic examination and CT pulmonary angiogram revealed a dilated communication between the right inferior pulmonary artery and left atrium. The patient was then referred for cardiac MRI. The MR imaging showed the following findings: Dilated right ventricle and atrium with Ostium secundum type of atrial septal defect. Large focal outpouching was noted arising from the right inferior pulmonary artery whose inferomedial portion appeared to communicate with left atrium. The final diagnosis was right pulmonary artery to left atrial fistula-Type I with ostium secundum type atrial septal defect. Midline sternotomy was performed for ligation of this fistula with septal correction. Post surgery, patient began to improve clinically and her saturation in room air increased to 92%ConclusionsRight pulmonary artery to left atrial fistula is different from the pulmonary AV fistula and its rarity directs the need for imaging to diagnose the condition and for management selection. The fistulous connection, which most frequently originates from the posterior wall of the descending branch of RPA and inserts into the LA, is readily seen on CT/catheter angiography. Due to the rarity of this entity and much fewer evidences in imaging, we have reported a type 1 right pulmonary artery to left atrium connection.

The Utility of CT Angiography in Neonates with Pulmonary Atresia with Intact Ventricular Septum and Concern for Right Ventricular Dependent Coronary Circulation: Case Series.

Up to one third of patients with pulmonary atresia with intact ventricular septum (PA-IVS) will have inadequate anterograde coronary blood flow and rely on fistulous connections from the right ventricle (RV) for myocardial perfusion, known as RV-dependent coronary circulation (RVDCC). Historically, identification of the extent of ventriculocoronary connections and coronary stenosis has required invasive imaging with cardiac catheterization and angiography. Cardiac computed tomography (CCT) potentially provides a less invasive imaging option for therapeutic planning in this group of patients. We describe six neonates with PA-IVS who underwent both CCT and cardiac catheterization at our institution prior to any surgical or transcatheter intervention between 2009 and 2019. Imaging was concerning for RVDCC in all six patients. The average tricuspid Z-score was - 4.19 (2.1 to - 5.34). Two patients underwent cardiac transplantation and two patients underwent ductal stenting. The overall mortality rate was 50%. CCT findings closely mirrored the findings of invasive cardiac catheterization and identified important morphological variations. The average radiation exposure (DLP) per CCT was (10.5mGycm, range 6-20). Technological improvements in CCT have enabled adequate visualization of coronary anomalies in children with comparable accuracy to cardiac catheterization, but considerably less radiation exposure. However, diagnosis of RVDCC requires direct right ventricular angiography. Therefore, the potential benefit of obtaining a CCT prior to catheterization for infants with PA-IVS is the ability to risk stratify, assist with procedural planning, and improve family counseling.

Management of an intercostal-pulmonary artery fistula in the setting of massive hemoptysis

Introduction: Intercostal artery to pulmonary artery fistulas is exceptionally rare. The few cases reported in the literature are often found in asymptomatic patients, but this physiology can result in massive hemoptysis and subsequent respiratory failure secondary to aspiration. Case Report: A male in his 40s presented to our tertiary community hospital with massive hemoptysis and a known diagnosis of Mycobacterium szulgai; his past surgical history was pertinent for a coronary artery bypass with chest tube placement four years prior to his presentation and for remote pneumothoraces bilaterally. Angiography identified a fistulous connection between multiple intercostal artery trunks to a right upper lobe pulmonary artery that was coil embolized, successfully resolving his hemoptysis. Conclusion: This case report investigates a potential complication of those in an active inflammatory state, such as a mycobacterium infection, and the opportunity for minimally invasive treatment for those with massive hemoptysis.

Abstract 15617: Severe Heart Failure: Fistulous Connection Between Ectatic Left Anterior Descending Artery, Coronary Sinus, and Left Ventricular Cavity

Introduction: Arteriovenous coronary fistula of LAD to the coronary sinus is a rare vascular anomaly present in 0.002% of the general population. We report a rare case of fistulous connection between exceptionally large LAD and coronary sinus into the LV cavity leading to severe systolic heart failure. Case: A 39-year-old male with no past medical history presented to the ED with complaints of dyspnea, chest pain and lower extremity edema for the past 3 months. The chest pain was substernal, squeezing, non-radiating, 2/10 in intensity, exacerbated by exertion and alleviated with rest. The patient did not have any cardiology work up in the past. Vitals were stable. The patient had irregular rhythm with prominent JVD and bilateral lower extremity edema on examination. Troponins were negative, BNP was elevated and thyroid function was normal. Chest x-ray showed cardiomegaly. EKG showed atrial fibrillation with no significant ST segment changes or Q waves. Echocardiogram showed severe systolic left ventricular dysfunction with an ejection fraction of 15-20% and moderate to severe secondary mitral regurgitation. Cardiac catheterization showed large ectatic LAD with mild stenosis in mid segment. An abnormal connection was noted between LAD and coronary sinus draining directly into the left ventricle. He was discharged on guideline directed medical therapy for heart failure. Discussion: Fistula between LAD, coronary sinus and LV cavity is a unique organic heart disease. Our patient presented with heart failure with no apparent identifiable cause. On angiography an ectatic LAD was connected to the coronary sinus and LV cavity which created a high output state on the LV. The management of this rare pathology is complex due to variable presentation and lack of specific treatment guidelines. Careful selection of certain cases for therapeutic intervention can result in better outcomes than medical therapy alone.

The Role of Interventional Radiology in the Diagnosis and Treatment of Pulmonary Arteriovenous Malformations.

Pulmonary arteriovenous malformations (PAVMs) are uncommon, predominantly congenital direct fistulous connections between the pulmonary arteries and pulmonary veins, resulting in a right to left shunt. Patients with PAVMs are usually asymptomatic with lesions detected incidentally when radiological imaging is performed for other indications. In this review, we discuss the classification and radiological features of PAVMs as well as their treatment and follow-up options, with a particular focus on percutaneous endovascular techniques and the evolution of the available equipment for treatment.

S3543 An Unusual Complication of Peptic Ulcer Disease

Introduction: In patients with severe peptic ulcer disease (PUD), perforation is a serious complication, often presenting with acute abdominal pain. Perforation occurs in approximately 5% of patients with PUD over their lifetime. Although fistulas have been reported as a potential complication of postoperative perforated peptic ulcer disease, we present a unique case of antral-abscess fistula complicated by duodenal adenocarcinoma. Case Description/Methods: A 57-year-old female presented to the hospital with a chief complaint of epigastric pain. The patient had a history of perforated gastric ulcer status post graham patch repair. Computed Tomography (CT) of abdomen revealed remote gastric perforation with chronic fistulous connection between the gastric antrum and an abscess along the superior margin of the gastric antrum, underneath the left liver. Upper GI endoscopy revealed diffuse mildly erythematous mucosa without bleeding in the stomach as well as non-bleeding large cratered chronic appearing duodenal ulcer with a clean ulcer base (Forrest Class III) in the duodenal bulb involving more than 90% of the duodenal circumference, causing narrowing at the duodenal sweep and 2nd portion of duodenum. There were multiple ulcer/mucosal changes spots of bluish/reddish concerning for non-bleeding visible vessel and fistula given the severity of the ulcer/mucosal changes. Subsequent duodenal ulcer biopsy revealed necrotic tissue with infiltrating cells which were significant for adenocarcinoma of the duodenum (Figure). Discussion: To our knowledge, this is the first report demonstrating antral stomach-abscess fistula with concomitant evidence of duodenal adenocarcinoma after perforated peptic ulcer disease. With this report, we not only aim to shed light on this unique complication but also to spark the scientific community to further investigate potential associations of duodenal adenocarcinoma including peptic ulcer disease.Figure 1.: Endoscopy of duodenum demonstrating ulcerations concerning for non-visible bleeding vessels and fistula.

P217 Pelvic mycoses— an unusual presentation of Rhizopus arrhizus in an ommunocompetent patient

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMIntroductionThe rare but increasingly identified infections caused by Mucorales are always detrimental to the patient due to rapid vascular invasion and the need for thorough surgical debridement and definitive antifungal therapy for its cure. Among the Mucorales, maximum cases have been reported among Mucor spp. and Rhizopus spp. Case: Here we present a case of a 9-year-old immunocompetent child presenting with abdominal pain and distension of 1-month duration followed by swelling of bilateral lower limbs, which was gradual in onset. Ultrasonography of the abdomen and pelvis was done which revealed a pelvic mass on the left side. The child developed acute urinary retention during the hospital stay, which was evaluated to reveal a fistulous connection between urethra and rectum for which transverse colostomy was done. The USG-guided biopsy of the left pelvic mass showed broad aseptate hyphae in Hematoxylin and Eosine staining whereas the KOH mount and culture were negative. The follow-up imaging with CT showed circumferential thickening of the recto-sigmoid region and involvement of the posterior bladder wall. Considering the rapidity of the spread of the infection, injection liposomal Amphotericin B at the dose of 5 mg/kg/d, i.v. was started and given for one week with minimal improvement. However, with this clinical picture and patient profile the diagnosis was strongly suspected to be of Basidiobolomycosis of rectosigmoid region. Treatment also was revised to injection of voriconazole at a dose 8 mg/kg/d, i.v. after loading dose which was later shifted to oral dose after 7 days. A repeat USG-guided biopsy was planned for gene sequencing, which identified the organism as Rhizopus arrhizus. On follow-up, patient showed no clinico-radiological improvement and in view of the mycological evidence, the anti-fungal was changed from voriconazole after 2 weeks to oral isavuconazole at the dose of 200 mg/d following the loading after which significant improvement was achieved and patient was discharged.ConclusionMold infection in the form of spreading rectosigmoid mass in an immunocompetent child usually suggests the picture of Basidiobolomycosis. Treating patients only on clinical grounds without mycological confirmation may lead to overlooking of Mucormycosis and may result in adverse outcomes. The diagnosis of Mucormycosis should always be considered as a differential for a fungal infection in the form of mass lesion in abdomen.

Novel endovascular technique for repair of superior mesenteric arteriovenous fistula with portal vein aneurysm

BackgroundA superior mesenteric arteriovenous fistula (SMAVF) is a rare, aberrant connection between the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV). Management includes either open surgical repair or endovascular repair with embolization coils or covered stents. We report a novel in-stent coil embolization technique successfully used for repair of a challenging SMAVF. Case presentationA 56-year-old man presented with an enlarging SMV and portal vein aneurysm. His history was significant for a small bowel resection of a desmoid tumor 14 years prior. Computed tomography (CT) angiography revealed a high-flow SMAVF in the midsegment of the SMA, and the patient was taken to the operating room for endovascular repair. Embolization was initially attempted with detachable coils, but this approach was aborted as the coils did not have sufficient purchase to anchor securely and would migrate into the portal venous system prior to full release and deployment. Placement of a covered stent in the SMA to exclude the fistulous connection was not feasible due to the presence of multiple adjacent major SMA branches. Therefore, a balloon-expandable covered stent was placed across the fistula and crushed distally to create a blind end into which embolization coils were able to nest without migrating. This was achieved with the use of multiple buddy wires to deploy a VBX balloon-expandable stent graft (WL Gore, Flagstaff, AZ) across the fistulous connection and crush the distal end of the stent with a buddy balloon. The funneled covered stent then served as a backstop for packing with embolization coils, and completion angiography demonstrated complete occlusion of the SMAVF and filling of all SMA branches. Both 6-month and 1-year postoperative surveillance CT scans confirmed continued resolution of the fistula. ConclusionThis case demonstrates a novel endovascular technique to create a funneled covered stent across a high-flow SMAVF as a platform to enable embolization and prevent coil migration. This in-stent coil embolization technique is a viable option for cases in which embolization coils and covered stents fail or are unsuitable.