Fistulous Connection Research Articles

Type II Mirizzi Syndrome: A Rare Complication of Gallstones

Introduction: To recognize clinical manifestations of type II Mirizzi syndrome (MS) in a patient with porcelain gallbladder. Case Report: A 64-year-old female presented with 3 weeks of abdominal discomfort, jaundice, clay colored stools, pruritus, dark urine, and weight loss. Abdomen was soft and non-tender. Laboratory studies were significant for AST 83 U/L, ALT 26 U/L, alk phos 468 U/L, and bilirubin 19.2 mg/dL. CT abdomen showed dilatation of intrahepatic ducts and common bile duct (CBD) with abrupt transition to normal. No stones were visualized but a calcified cystic lesion adjacent to the left lobe of the liver was seen (Figure 1). An ERCP done showed a 16-mm stone in the middle of CBD. Cystic duct was small but a fistula connecting the gallbladder to extrahepatic ducts at the bifurcation of common hepatic duct was identified (Figure 2). Initial attempts to perform mechanical lithotripsy using a basket were unsuccessful as the basket broke. Stent was placed for decompression and ERCP with EHL was repeated in 4 weeks. Complete stone removal was accomplished with clinical and chemical resolution of biliary obstruction.Figure 1: CT of the abdomen showing a red arrow marking the classic image of a porcelain gallbladder.Figure 2: ERCP image showing CBD stone and a type II Mirizzi syndrome.Discussion: Type II MS is characterized by obstructive picture and a fistulous connection between the gallbladder and the biliary tree involving less than one-third of the circumference of the duct wall. Patient can be managed endoscopically. Our patient was also found to have a porcelain gallbladder, which is rare complication of chronic cholecystitis and is associated with cholangiocarcinoma (2%; incomplete type > complete type). Cholecystectomy is advocated by most.

The Failure of Operation for Spinal Dural Arteriovenous Fistula demonstrated by Intraoperative Indocyanine Green Video-Angiography

Our objective was to both describe and show (via video) the use of intraoperative indocyanine green (ICG) video-angiography for obliteration of a spinal dural arteriovenous fistula (DAVF). ICG video-angiography is an emerging tool for delineating intraoperative vascular anatomy with significant potential in the treatment of vascular diseases in the spine. The authors presented the case of a 49-year-old woman with progressive and debilitating bilateral lower-extremity weakness. The patient was diagnosed with a spinal AVM of the 10th thoracic vertebra based on the results of conventional spinal angiography. The patient underwent T8-9 laminotomy for microsurgical clip occlusion. Intraoperative ICG video-angiography was used before clip placement to identify the arterialized veins of the fistula, as well as after clip placement to confirm obliteration of the fistulous connection. The authors failed to restore the normal blood flow through repeated temporary clip and ICG angiography. In conclusion, intraoperative ICG video-angiography serves an important role in the microsurgical treatment of DAVF. It is simple process that provides real-time information regarding both the precise location of spinal DAVF and the result of spinal DAVF obliteration. The lack of understanding of anomalous vascular anatomy could be the cause of failure.

Cytological evaluation of peritoneal fluid with special reference to malignancy

Aspiration of serous cavities is a simple and relatively non invasive technique to achieve a diagnosis. Cytological examination of serous fluid is of paramount importance , it revelas information about inflammatory conditions of serous membrane,infection by bacteria, fungi,virus,finding of cancer cells and also supply evidence of fistulous connection with a serous cavity. Cytological examination not only helps for the diagnosis of cancer but also for staging and prognosis of disease.It is a complete diagnostic modality which aims at pointing out the etiology of effusion as well as prognosis of disease.Methods A total of 160 peritoneal effusion samples received for cytopathological examination over a 1 year period were analyzed. Cytomorphological features of neoplastic effusions were studied. Special stains and immunocytochemistry (ICC) were performed to aid the diagnosis in difficult cases.Result The peritoneal effusion samples comprised of 160 cases out of which adenocarcinoma was found to be the cause of metastatic malignant effusion.Reactive mesothelial cells were the most challenging to differentiate from malignant effusion cytology. Immunohistochemical staining was useful to arrive at a definitive diagnosis in difficult cases.Conclusion Cytology is a useful tool to detect malignant effusions. Immunohistochemical staining must be performed in difficult cases to differentiate metastatic epithelial cells from reactive mesothelial cells,which is a benign condition.

Spinal dural arteriovenous fistula associated with L-4 isthmic spondylolisthesis

The authors describe a case of a 79-year-old man with a lumbar spinal dural arteriovenous fistula (DAVF) and isthmic spondylolisthesis at the same level. The patient's thoracic spine MRI study demonstrated swelling and increased T2 signal in the spinal cord and regional dilated perimedullary vessels. Lumbar spine MRI showed L-4 isthmic spondylolisthesis with severe bilateral L4-5 foraminal stenoses. Spinal angiography revealed a fistulous connection at the left L-4 nerve root sleeve between perimedullary veins and a dural branch of the L-4 radicular artery. Based on previous reports about secondary spinal DAVFs, the abnormal vascular communication likely developed secondary to the microtrauma and inflammation on the left L-4 nerve root sleeve, which was attributable to the isthmic spondylolisthesis. The authors performed disconnection of the arteriovenous shunt as well as an L4-5 decompression and posterior instrumented fusion with pedicle screws. The patient's postoperative course was uneventful, and he improved neurologically. It is important to bear in mind that a spinal DAVF may develop as a consequence of any sort of trauma or inflammation involving nerve roots. One should consider the concomitant treatment of both the spinal DAVF and the underlying pathology that may have given rise to the spinal DAVF.

Coronary to pulmonary connection: fistula or collateral?

A 51-year-old woman with a history of chronic obstructive lungs disease and cor pulmonale was referred to our institution for stable angina pectoris. Coronary angiography did not show any atherosclerotic lesion, but left coronary angiography showed the presence of two small fistulae from both the left anterior descending artery and the left main coronary artery to the pulmonary artery and right coronary angiography showed significant contrast passing from the right coronary artery into the left superior pulmonary vasculature. The most prominent angiographic findings were the lack of competition between the flow from the fistulae to the pulmonary artery and the native pulmonary artery flow and the left pulmonary vascular bed was filled completely by the contrast agent (see Figure 1, panel A-B and online video 1). An anomaly of the pulmonary arterial system was suspected and multislice computed tomography was done. Interestingly, the tomographic images showed a filling defect in the left main pulmonary artery after the pulmonary bifurcation, which was compatible with partial pulmonary agenesis. (see Figure 1, panel C). Connections between the coronary arterial system and the pulmonary arterial vasculature are relatively uncommon.1 The most important characteristic of the pattern of flow dynamics of these fistulous connections between the coronary artery and pulmonary artery is the competition of fistulous flow with the native pulmonary artery flow. Angiographically, this competitive flow appears as dissolution of contrast agent in the pulmonary artery. In online video 2 (right panel), an angiographic image of a 28-year-old patient who had a fistula from the circumflex artery to the pulmonary artery, which is compatible with the fistulous characteristics mentioned above, is presented. In the literature, coronary to pulmonary collateral flow associated with pulmonary artery hypoplasia has been described previously.2 If the connection between the Coronary to pulmonary connection: fistula or collateral?

Percutaneous Transfacial Direct Embolization of an Intraosseous Dural Arteriovenous Fistula

An intraosseous dural arteriovenous fistula (DAVF) is a rare cerebrovascular disease. The fistulous connection occurs within intraosseous diploic or transosseous emissary veins causing dilated intraosseous vascular pouches. To the authors' knowledge, this report describes the first percutaneous transfacial direct embolization of an intraosseous DAVF. A man in his 50s with blue rubber bleb nevus syndrome presented with headaches, imbalance, decreased visual acuity bilaterally, and left eye proptosis and chemosis. Imaging demonstrated an extensive intraosseous DAVF with dilated intraosseous vascular pouches throughout his cranial base and intraorbital venous congestion. He underwent staged endovascular treatment with the goal to improve his ocular symptoms. Transarterial and transvenous approaches failed to provide adequate access to the intraosseous vascular pouches. A direct, percutaneous transfacial approach was used to access the pouches for embolization with coils and liquid embolic material. Postoperative angiography demonstrated successful embolization of the pouch within the left pterygoid wing, reduced opacification of the intraosseous fistula, and elimination of intraorbital venous congestion. At 9-month follow-up, the patient's headaches had resolved, and his ocular symptomatology had improved. Endovascular access to an intraosseous DAVF is limited by the size and location of the intraosseous vascular pouches. In this case, a direct transfacial approach under image guidance facilitated access and embolization, which led to an improvement in the patient's symptoms. This technique is a novel approach for DAVF management.

Pancreatic Arteriovenous Malformation: A Rare Cause of Gastrointestinal Bleeding

Purpose: A 48-year-old African-American man presented with 6 months of left upper quadrant (LUQ) abdominal pain and weight loss. His history was significant for type 2 diabetes. On physical exam, the abdomen was tender to palpation in the LUQ. Blood counts, chemistry, and hepatobiliary tests were within normal limits. CT of the abdomen showed a heterogenous pancreatic head, distal atrophy, pancreatic ductal dilation of 7 mm, dilated portal and splenic veins, and choledochocele. After pain was controlled, he was discharged with outpatient follow-up. A month later, he was admitted for hematemesis. He had mild anemia, transaminitis (ALT 125, AST 220), with normal coagulation and pancreatic enzymes. EGD showed thickened stomach folds, without varices or active bleeding. MRI revealed nodular enhancement throughout the pancreatic parenchyma, communicating with splenic vein and portal veins, suspicious for pancreatic arterio-venous malformation (AVM). A 1.8-cm choledochal cyst communicating with the second portion of the duodenum and a 1-cm choledodochocele were found in the head of the pancreas. Dense material in the cyst was suspicious for bleeding. EUS showed collateral vessels from the head to the tail of the pancreas and 2.6 cm choledochal cyst communicating with the distal common bile duct and duodenal wall. ERCP revealed a type III choledochal cyst with a fistulous connection to the duodenum above the ampulla and no evidence of active bleeding. Abdominal angiogram confirmed the diagnosis of pancreatic AVM supplied by the superior mesenteric and celiac arteries, with early filling of a dilated portal vein. Transjugular liver biopsy showed mild fibrosis and glycogenated hepatocytes. Right hepatic vein pressure was 21 mmHg, with wedge of 24 mmHg and gradient of 3 mmHg, which was not consistent with portal hypertension. He was managed symptomatically. At 6 months of follow-up, pain is well-controlled without recurrence of GI bleeding. Pancreatic AVM is a rare vascular anomaly in which blood flows from the arterial system directly into the portal venous system without passing through the capillaries in the pancreas. Though it can be asymptomatic, it can also present as abdominal pain, GI bleeding, portal hypertension, and pancreatitis. Our patient had abdominal pain and GI bleeding. The mechanism of bleeding in our patient was likely from erosion of the AVM in the choledochal cyst. Portal hypertension was ruled out by hepatic venous pressure measurement, and no varices were found in EGD. While the diagnostic study of choice has been angiography, noninvasive studies such as EUS, CT, and MRI may assist in diagnosis.

Coronary Artery to Right Atrium Fistula Associated With First Degree Atrioventricular Block: A Rare Association.

A 40 year-old man with no significant past history except for asymptomatic 1st degree heart block presented for general health screen. Clinical examination revealed a loud continuous murmur with diastolic accentuation in the left precordium, noncollapsing pulse, and no differential pulses in the upper and lower limbs. The ECG showed normal sinus rhythm with PR interval of 220 milliseconds. Transthoracic echocardiogram (Figure ​(Figure1)1) showed a dilated right coronary artery that was enlarged, forming multiple saccular aneurysms distally that drain into the roof of right atrium. The right heart was normal in size and function. CT angiogram (Figure ​(Figure2)2) later confirmed the presence of a coronary artery fistula from the right coronary artery draining into the right atrium. Right coronary artery is dilated and the distal segment of the RCA is tortuous and aneurismal. Nuclear myocardial perfusion imaging showed no inducible ischemia during exercise stress. He declined cardiac catheterization, and was advised for corrective surgery. This case illustrated a rare saccular aneurysm formation in a right coronary artery to right atrium (coronary-cameral) fistula associated with 1st degree atrioventricular (AV) block. Coronary arteriovenous fistula (CAVF) arises as a persistence of sinusoidal connections between the lumens of the primitive tubular heart in the early embryologic period. It is reported in 0.1%–0.2% of all cases of selective coronary angiography[1]. Most fistulae originate from the right coronary artery (60%) and terminate in the right side of the heart such the right ventricle or atrium, coronary sinus, and pulmonary vasculature. Most often congenital, a CAVF may rarely arise as a consequence of surgical complication, endomyocardial biopsy, invasive procedures[2, 3] or penetrating trauma. It could cause myocardial stealing due to run-off from the coronary vasculature to a low-pressure receiving cavity. Coronary artery that feeds the fistula progressively dilates, leading to complications of frank aneurysmal formation and mural thrombosis. Hence, all CAVF ought to be closed except for trivial ones. The evolution of 1st degree AV block in our case may reflect a flow limitation to atrioventricular (AV) node directly caused by the CAVF. CT angiogram has now emerged as an excellent imaging technique to delineate the lesion anatomy[4-6] CAVF generally requires closure. Transcatheter embolization techniques using coils, bags, or other devices can be performed successfully and safely, and are now the treatment modality of choice [7]. CAVFs with multiple connections, circuitous routes, and acute angulations may however be better treated surgically. Figure 1. Transthoracic echocardiogram performed showed the tubular structure coming off the right coronary cusp (bold arrow, image A); saccular formations adjacent to the aortic root in short axis and apical 4 chamber view (bold arrows, image B and C); as well as predominantly diastolic turbulent flow within the saccular formations (image D). Figure 2. Cardiac multidetector computed tomography (MDCT) angiogram volume rendering reconstruction of cardiac structures (images A-B) and multiplanar reconstruction images (images C-D) showed a dilated, tortuous right coronary artery (RCA) that eventually gave off a fistulous connection into the right atrium (RA).

Scalp Arteriovenous Fistula Following Hair Transplantation

Arteriovenous fistulae (AVF) were first described by Hunter in 1757. The outdated term of cirsoid aneurysm was applied to vascular malformations of the scalp in 1833 by Brecht. An AVF is a fistulous connection between the arterial feeding vessels of the scalp and the draining veins, bypassing an intervening capillary bed [6]. Although AVF may be congenital, they are more often acquired due to injury of neighboring vessels [2, 8], including iatrogenic microtraumatisms such as hair transplantation. Among the various existing procedures for baldness, punch autograft technique is one of the preferred for its simplicity, effectiveness, and safety. AVF of the scalp is a very rare complication among all procedures of hair restoration done each year in the world, since about 40 years. Suspected clinical diagnosis was easily made but further vascular investigations, especially computed tomography angiography (CTA), were helpful for diagnosis confirmation of this rare pathology and to plan the treatment. Case Report

Coil embolization of a symptomatic left internal mammary arteriovenous fistula

Internal mammary artery (IMA) arteriovenous fistulae (AVF) are exceedingly rare. There have been a few case reports documenting incidences of IMA AVFs arising from traumatic, iatrogenic, and congenital causes. Recommendations for management of IMA AVFs vary from open surgical ligation-excision to transcatheter embolization to observation. We present an unusual case of a patient who presented with ventricular arrhythmias and heart failure symptoms due to a left IMA AVF that formed after open heart surgery. The patient ultimately underwent percutaneous embolization of the fistulous connection.

Imaging of disorder of sex development

BACKGROUND AND OBJECTIVESDisorders of sex development (DSDs), formerly termed ambiguous genitalia, are a group of conditions where the external genitalia appear abnormal. It represents a true medical and social emergency that needs a multidisciplinary team approach for elucidation. The pediatric radiologist plays an important role in defining the genital anatomy that remains one of the most important factors in sex determination, in addition to chromosomal analysis.DESIGN AND SETTINGSA retrospective study, conducted between January 1995 and December 2010.MATERIALS AND METHODSImaging studies (ultrasound, genitogram, and/or magnetic resonance imaging) were performed in patients with ambiguous genitalia, confirmed by chromosomal analysis and appropriate hormonal investigations.RESULTSThe sensitivity of ultrasound is 89.5%, while its specificity reaches 100%. Retrograde genitogram is more invasive and less sensitive, as the yield of determining the presence of a uterus ± vagina is 84.2%. However, magnetic resonance imaging (MRI) is more sensitive for gonadal tissue identification. Its specificity reaches up to 100% and can provide detailed internal structures (uterus, fallopian tubes, and gonads).CONCLUSIONUltrasound examination is still the main modality of choice for screening patients with ambiguous genitalia. It is cheap and readily available everywhere. In addition to elucidating the uterus in 89.5%, it can also give more information on the adrenal glands. However, genitography is good—84.2% in elucidating genital anatomy—but it gives no information of the gonads and it is time consuming and invasive. MRI is helpful in cases with equivocal ultrasound, reaches 100% in elucidating internal extractor, and therefore could be reserved for that.

Fistulous connection of left circumflex coronary artery to coronary sinus presenting with massive pericardial effusion

Fistulous connection of left circumflex coronary artery to coronary sinus presenting with massive pericardial effusion

Case series of a rare complication of CABG

There are few reports in the literature on the development of a fistulous connection between the left internal mammary artery (LIMA) and the pulmonary vasculature (PV) after coronary artery bypass grafting (CABG). This type of fistula may cause angina after CABG. Various mechanisms in the pathophysiology of this rare condition have been proposed. We evaluated 537consecutive patients with CABG surgery who underwent coronary angiography at our institution between January 2011 and March 2012. The post-CABG angiograms were evaluated for LIMA-PV fistula formation. Presence of a LIMA-PV fistula was defined as opacification of the PV or parenchyma after injection of radiopaque contrast medium into the LIMA. We found that 5 of 537patients (0.93 %) had a LIMA-PV fistula on post-CABG coronary angiograms. The mean age of patients with a LIMA-PV fistula was 61.4years (range, 51-72years) and all patients were male. Coronary angiography was performed in the setting of myocardial infarction for 2patients with a LIMA-PV fistula, and stable angina pectoris was the indication for coronary angiography in the remaining 3patients. The mean diagnosis time of LIMA-PV fistula after CABG was 3.4years (range, 1-9years). None of the patients had a history of redo-CABG, perioperative mediastinitis, or pneumonia. LIMA-PV fistulas may occur more frequently than reported on post-CABG angiogram findings. Angina in post-CABG patients may be associated with a LIMA-PV fistula, and selective cannulation of the LIMA with careful evaluation of the angiographic images may provide proper diagnosis and treatment of this entity.

Supraclinoid internal carotid artery–inferior petrosal sinus arteriovenous fistula after high-voltage electrical burn injury

High-voltage electrical burns can cause immediate and long-term neurological and cerebrovascular injuries. The authors present a 21-year-old man who developed an intracranial arteriovenous fistula secondary to high-voltage electrical injury. CT angiography demonstrated a left supraclinoid internal carotid artery (ICA)–inferior petrosal sinus (IPS) fistula. A subsequent angiogram revealed an irregularity of the cavernous and supraclinoid ICA with stenosis involving the supraclinoid segment and a fistulous connection between the ICA and IPS distal to the ophthalmic take-off and proximal to the anterior choroidal artery. The patient underwent a decompressive hemicraniectomy and clip-wrapping of his ICA pseudoaneurysm with successful obliteration of the fistulous connection. To our knowledge, this is the first report of an intracranial arteriovenous fistula secondary to an electrical burn injury.

Aorta–to–Pulmonary Vein Fistula in an Asymptomatic 25-Year-Old Man

A 25-year-old man with no significant medical history was found to have a continuous murmur along the left sternal border on routine physical examination performed in preparation for running a marathon. Echocardiography showed a dilated left ventricle with normal function and continuous high-velocity flow in an aberrant vessel in close vicinity to the abdominal aorta (Movie I in the online-only Data Supplement). Chest x-ray (posterior-anterior and lateral projections, Figure 1) disclosed conglomeration of tubular densities in a scimitar pattern in the right lower lobe suggestive of anomalous pulmonary venous return of right lower lobe (scimitar syndrome; anomalous drainage of right lung pulmonary veins into the inferior vena cava). Cardiac magnetic resonance imaging (MRI) not only demonstrated normal drainage of all 4 pulmonary veins into the left atrium but also revealed an aberrant vessel (Movie II in the online-only Data Supplement) extending between the abdominal aorta and the right inferior pulmonary vein with an elevated systemic-to-pulmonary flow ratio of 1.8, consistent with a large left-to-left shunt. Cardiac computed tomography (CT) confirmed the presence of a large fistulous connection between the abdominal aorta and the right inferior …

Transfemoral venous approach for Onyx embolization of anterior fossa dural arteriovenous fistulae

BackgroundDural arteriovenous fistulae (dAVF) of the anterior fossa have a malignant course since they exclusively drain into cortical frontal veins and warrant aggressive treatment. Classically, these lesions have been treated...

Endovascular treatment for dural arteriovenous fistula at the foramen magnum: Report of five consecutive patients and experience with balloon-augmented transarterial Onyx injection

Foramen magnum dural arteriovenous fistulas (DAVF) with perimedullary venous drainage represent a small minority of intracranial DAVF, and only a number of small series with limited cases have been reported. The purpose of this retrospective study is to summarize experience of transarterial Onyx embolisation in the treatment of these lesions, with emphasis on the balloon-augmented technique. Five consecutive patients with DAVF at the foramen magnum were treated by transarterial embolisation using the Onyx system. Their symptoms included myelopathy (n=4) and SAH (n=1). Suppliers were from the vertebral artery (VA) (n=4), occipital artery (OA) (n=4), and ascending pharyngeal artery (APA) (n=2), with drainage to the perimedullary veins. After catheterization of the dilated supplier, the fistulous connections, proximal draining veins and appropriate distal segment of the feeders of these DAVF were transarterial embolized using Onyx-18. In three patients, balloon-augmented technique was used to assist embolisation. The technical feasibility of the procedure, angiographic results, and clinical outcome were evaluated. In every case, complete obliteration was achieved. Neither intraprocedural vessel rupture nor other procedure-related complications occurred. The results remained stable in all patients on follow-up angiograms (mean, 7.2 months). At the last clinical follow-up (mean, 17.6 months), two patients showed complete resolution of the initial symptoms, and three patients showed significant improvement. We found that Onyx embolisation is a feasible and safe alternative to open surgery in the treatment of selective DAVF at the foramen magnum. The balloon-augmented technique widens indications for transarterial Onyx packing of these lesions, and improved safety of the procedure.

Isolated Absence of Coronary Sinus: Two Cases Report

Coronary sinus (CS) is the venous drainage system of the heart. Absence of the coronary sinus or atresia of ostium of the CS are rarely seen cardiac malformations. Congenital absence of CS usually is found together with other cardiac malformations, however, isolated congenital absence of CS is very rare. Multiple coronary-cameral fistulous connections, through which the blood drains into one of the cardiac chambers, are commonly seen in patients with CS abnormalities. Herein we present a case two cases of total absence of CS with a venous system draining directly into the left ventricle through Thebesian veins.

An unusual fistula closed by percutaneous coil embolisation

A 25-year-old male patient was admitted for assessment of increasing shortness of breath and decreased transcutaneous oxygen saturation (91 %). He had a complex congenital heart defect, involving a dysplastic monocusp tricuspid valve and pulmonary valve atresia. The latter was palliated shortly after birth by a Brock procedure (entailing infundibular resection and pulmonary valvotomy). An atrial septal defect was surgically closed when he was 6 years old and a homograft was inserted in the right ventricular outflow tract at the age of 15. Replacement by a second homograft at the age of 23 was necessary together with tricuspid valvoplasty because of severe insufficiency of both valves. Apart from moderate pulmonary homograft stenosis (PHS) and re-occurrence of moderate to severe tricuspid insufficiency (TI) resulting in right heart failure, a right-left shunt was detected on transoesophageal echocardiography during intravenous agitated saline bubble-contrast injection, although the repaired atrial septum was intact. Invasive evaluation confirmed moderate to severe TI and a peak-to-peak gradient of 40 mmHg over the homograft. Right atrial pressures were above 20 mmHg. Contrast injection in the superior vena cava showed a very tortuous fistulous connection originating from the left axillary vein and draining towards the left atrium (Fig. 1, panel A and B). It was decided to close the fistula percutaneously and 4 coils (3 x IMWCE-3-PDA3 and 1 x IMWCE-3-PDA5, COOK MEDICAL, Bloomington, USA) were placed in the fistula, effectively occluding the vessel (panel C). The transcutaneous oxygen saturation increased slightly. Further management regarding the TI and PHS will be discussed with one option being percutaneous placement of a pulmonary valve (Medtronic, Minneapolis, USA), possibly in combination with another transcatheter valve prosthesis in tricuspid position to lower the right heart filling pressures. Fig. 1 a Contrast injection in the superior vena cava (SVC) showing a fistula (arrow) originating from the left axillary vein (AV). The right atrium (RA) is grossly enlarged (LIV left innominate vein). b Selective contrast injection in the fistula (arrow) reveals ...

Application of indocyanine green videoangiography in surgery for spinal vascular malformations

We present our recent experience with indocyanine green videoangiography (ICGVA) in intra-operative evaluation of two patients with dorsal spinal dural arteriovenous fistula (SDAVF) and one patient with conus medullaris arteriovenous malformation (AVM). To our knowledge, the latter is the first report of this in the literature. Intra-operative ICGVA was used to identify an early filling vessel and to obliterate the site of fistulous connection. This was confirmed by a repeat ICGVA study and correlated with post-operative digital subtraction angiography (DSA). The abnormal fistulous site was identified in all three patients and disconnected. Complete obliteration was confirmed in all patients using ICGVA and with post-operative imaging. There was no untoward reaction to the dye injection. We conclude that ICGVA is a useful adjunct in surgical treatment of spinal vascular malformations since it is a real-time, non-invasive, radiation-free technique with good image resolution, and is repeatable and easily reproducible. Technical disadvantages can be minimized by proper exposure of the operative field.