High-flow Fistula Research Articles

Urgent treatment of severe subarachnoid hemorrhage caused by ruptured traumatic aneurysm of the cavernous internal carotid artery using coil embolization followed by superficial temporal artery-middle cerebral artery anastomosis: A case report

Background Traumatic aneurysm of the cavernous internal carotid artery (ICA) with extension into the subarachnoid space is associated with increased risk of fatality especially when it is accompanied by severe subarachnoid hemorrhage (SAH). Only cases of patients who survived the acute stage and who were treated in a delayed setting have been reported. There has been no successfully treated case immediately after an injury. Case Description We encountered a 48-year-old man who presented with dense SAH immediately after being involved in a motor vehicle accident. Emergent angiography revealed traumatic aneurysm of the left cavernous ICA with extension beyond the superior wall of the cavernous sinus into the subarachnoid space and concomitant direct high-flow carotid cavernous fistula. Detachable platinum coil occlusion of the cavernous ICA followed by superficial temporal artery-middle cerebral artery anastomosis on day 0 and aggressive therapy to SAH, including ventriculocisternal irrigation and drainage, was performed. The patient eventually made a good recovery. Conclusion Considering the extremely poor prognosis and unstable nature of a ruptured traumatic aneurysm with extensive SAH in the acute stage, definitive and immediate prevention of rebleeding in conjunction with proper revascularization would be warranted, such as in the present case.

The management of hemodialysis arteriovenous fistulas in well functioning renal transplanted patients: Many doubts, few certainties

Vascular access (VA) for hemodialysis (HD) is one of the most important clinical problems in end-stage renal disease (ESRD) patients because it can limit a life support system and can influence long-term dialysis patient survival. Nevertheless, VA becomes useless after a successful renal transplant. Therefore, we wanted to evaluate the natural history of arteriovenous fistulas (AVF) in renal transplanted patients and the possibility of maintaining the fistula as patent or not. A retrospective study was conducted to evaluate kidney transplant patients in our unit from April 1994 to April 2004. We studied 542 patients. There were 365 patients with a well functioning kidney. Eighty-six patients died. Ninety-one patients were put back on dialysis: 89 patients on HD and two patients on CAPD. Of the 365 patients with functioning kidney transplants, 198 patients demonstrated a patent fistula, while 167 patients had a closed fistula. One hundred and twenty-five patients had a spontaneous closure and 42 patients had a surgical closure. Of the 89 patients put back on dialysis, 49 patients used the previous AVF, while it was necessary to create a new VA in 40 patients. As demonstrated by the results of our study, after renal transplantation the possibility of spontaneous AVF closure caused by a thrombosis is not a rare event. The dilemma is whether to preserve a fistula that could be useful in case of restarting HD or to perform a systematic fistula closure because of cardiac output and cardiac failure risks. Concerning this question there is no consensus between different authors in the literature. In reviewing the literature and analyzing our data, we conclude that the definite indications for AVF closure in well functioning renal transplanted patients are heart failure, high flow fistula, VA complications and important aesthetic reasons. Routine AVF closure is not indicated until prospective and randomized studies can demonstrate the ability of this procedure to reduce the high incidence of cardiac morbidity and mortality that is present, even after renal transplantation.

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.

Endovascular Treatment of AVMs in Glasgow

The Institute of Neurological Sciences (INS) at the Southern General Hospital in Glasgow is the largest Neuroscience Centre in Scotland, and among the largest in the UK. The other 3 Scottish centres are Aberdeen, Dundee and Edinburgh. Scotland itself has a population of approximately 5.2 million people and the INS in Glasgow provides neurointervention cover to almost 3 million of these. Referrals also come from the rest of Britain and overseas (North Africa, Middle-East and Asia). Glasgow has been nominated as one of two centres in the UK for management of neonatal high-flow fistulae, and has the largest experience in the UK for management of cervico-facial vascular malformations. There are 3 consultant interventional neuroradiologists (in addition to 6 purely diagnostic neuroradiologists) and two fellows (at least one of whom is training in neurointervention). Overseas trainees are sometimes accommodated, most recently from Greece and Thailand. Patients requiring interventional neuroradiology are usually admitted into the neurosurgery unit, although care is shared with the neuroradiologists. An AVM clinic is run jointly with neurosurgical colleagues, to which most (but not all) AVM patients are referred, and close links are maintained with the National Stereotactic Radiosurgery Centre in Sheffield (which has overwhelmingly, the largest experience in the UK for the radiosurgical treatment of AVMs). The Scottish Intracranial Vascular Malformations Study (SIVMS) is a collaborative epidemiological study between the four Scottish centres1,2,5.

Surgery of Internal Carotid Artery within the Parasellar Space (CS)

Despite incredible success in endovascular treatment of intracranial vascular lesions (parasellar large and giant aneurysms), those likely to present with periorbital pain and neurological symptoms—as well as the associated risk of creating spontaneous high-flow fistulae, even devastating SAH—cannot be effectively and completely eliminated from the cerebral circulation by endovascular techniques without sacrificing the ICA. For such lesions, the extradural approach provides a safe, efficient, practical surgical method in which the lesion might be successfully excluded, and the patency of the ICA preserved. The second category of the ICA lesions necessitates that the surgeon deal with high-flow CC fistulae, completely trans-sected ICA, and/or transpierced ICA in the region. Among these absolute indications for surgical treatment, other vascular lesions in the parasellar space will be discussed on the basis of the author's experience with more than 250 personally executed procedures for vascular lesions in the parasellar space.

High-Flow Traumatic arotico-Jugular Fistula Manifesting as Venous Hypertensive Encephalopathy

We report the clinical and angiographic findings in a patient who presented with venous hypertensive encephalopathy secondary to a traumatic carotico-jugular fistula. Endovascular entrapment of the fistula by occluding the common carotid artery and internal jugular vein at the base of the skull resulted in near total improvement of the patient's neurological status.

Pediatric nonvertebral paraspinal arteriovenous fistulas along the segmental nerve: clinical, imaging, and therapeutic considerations

The authors characterize the clinical presentation and imaging features of paraspinal nonvertebral arteriovenous fistulas (AVFs) along the segmental nerve and describe their endovascular treatment. The authors undertook a retrospective review of medical records, imaging, and treatment of patients with endovascular problems spanning the period from 1985 to 2003. Five pediatric patients (2-3 years of age) received diagnoses of nonvertebral paraspinal AVFs along the segmental nerve. All patients presented with an incidentally discovered continuous murmur over the paraspinal or parasternal regions. All patients were neurologically intact; two patients had cardiomegaly. The AVF was found in the midthoracic level in four patients and at L-3 in one patient. All AVFs were high-flow single-hole fistulas at the neural foramen with venous drainage into paraspinal and epidural veins but without intradural reflux. All fistulas were endovascularly occluded in the same session as diagnostic angiography took place. The fistula was completely occluded, with detachable coils in one case and with N-butyl-cyanoacrylate (NBCA) in four cases. Before NBCA injection, the flow through the fistula was decreased either by placing coils distal to the fistula or by inflating a balloon proximally. No signs of recanalization appeared on short-term follow-up magnetic resonance imaging in all patients. All patients remained neurologically intact at the last available follow-up session (mean 6 years). Nonvertebral paraspinal AVFs along the segmental nerve are specific disease entities seen in children presenting with bruit and cardiomegaly. Endovascular embolization should be the treatment of choice for this rare disease.

Endovascular treatment of traumatic femoral arteriovenous fistula

Arteriovenous fistulae are common complications of vascular trauma. These fistulae may cause cardiac dysfunction and limb-threatening complication. Therefore, prompt diagnosis and definitive treatment are essential. The development of endovascular techniques have provide new alternatives to surgery in these cases as other vascular lesions. We reported a case of high-flow femoral arteriovenous fistulae after gunshot injury that was treated with endovascular means.

Application of Temporary Filter During Percutaneous Transcatheter Embolization with Macro Coils of High-flow Massive Renal Arteriovenous Fistula

Angiographic evaluation and management of renal arteriovenous fistula (AVF) with embolization has become the treatment of choice replacing, in most of the cases, surgical intervention.We describe a case of a high-flow post-traumatic massive renal AVF in a 37-year-old man successfully treated with detachable stainless steel macro coils in which a temporary filter was applied to avoid coil migration. The use of a suprarenal retrievable filter, a minimally invasive manoeuvre, could considerably improve the safety of macro coils embolization of massive renal AVFs.

Application of Temporary Filter During Percutaneous Transcatheter Embolization with Macro Coils of High-flow Massive Renal Arteriovenous Fistula

Angiographic evaluation and management of renal arteriovenous fistula (AVF) with embolization has become the treatment of choice replacing, in most of the cases, surgical intervention.We describe a case of a high-flow post-traumatic massive renal AVF in a 37-year-old man successfully treated with detachable stainless steel macro coils in which a temporary filter was applied to avoid coil migration. The use of a suprarenal retrievable filter, a minimally invasive manoeuvre, could considerably improve the safety of macro coils embolization of massive renal AVFs.

The thrill is gone: Catheter-based exclusion of a posttraumatic arteriovenous fistula with a covered stent graft

Posttraumatic arteriovenous (AV) fistulae of the lower extremities may result from accidental trauma or iatrogenic surgical injuries. Large high-flow fistulae are commonly associated with disabling localized symptoms and impaired wound healing. Therapeutic options are particularly challenging for AV fistulae involving the infrapopliteal circulation. Surgical repair may further delay healing and contribute to greater morbidity. Alternatively, percutaneous coil occlusion in large high-flow fistulae mayenable coil embolization to the pulmonary circulation. Using a balloon-expandable covered stent graft, we describe the percutaneous exclusion of a large posttraumatic infrapopliteal AV fistula with immediate clinical symptom improvement and resolution within 3 months following intervention. No clinical symptom recurrence was documented at a 9-month follow-up visit.

Bilateral carotid-cavernous fistula following head trauma: Possible worsening of brain injury following balloon catheter occlusion?

A 68-year-old woman developed right pulsatile exophtalmos in the early course of facial and head trauma. Investigations by visual evoked potentials suggested the presence of a bilateral prechiasmatic lesion. Intraocular pressure rapidly increased and a high-flow carotid-cavernous fistula was evident at carotid angiography. Immediately after the treatment of the right fistula by balloon embolisation, a systolic bruit was noted over the left eyeball and angiography disclosed the presence of a left carotid-cavernous fistula that was treated by the same approach. The patient developed brain oedema leading to death and we postulated that reestablishment of normal cerebral perfusion after abrupt closure of the fistulas may have played a deleterious role.

Effect of surgical banding of a high-flow fistula on access flow and cardiac output: Intraoperative and long-term measurements

Creation of either a natural arteriovenous graft or a fistula as a vascular access to support long-term hemodialysis can lead to "high-output" cardiac failure. The authors describe a patient who underwent surgical banding of an upper arm arteriovenous fistula. Access flow and cardiac output were measured not only pre- and postoperatively but also intraoperatively using a modified Swan Ganz catheter, originally developed to measure access flows during radiologic procedures. Banding resulted in a significant decrease in access flow and cardiac output, which was sustained for up to 1 year postoperatively.

Spontaneous Thrombosis of a High-Flow Carotid-Cavernous Fistula after Failed Transarterial Balloon Occlusion

A 62-year-old man with a traumatic high-flow right carotid-cavernous fistula was treated by transarterial balloon occlusion technique. However, because of the relatively small size of the fistula, the balloon could not enter into the cavernous sinus via the fistula. During the procedure, the shunt flow decreased significantly, and we stopped the procedure. Follow-up angiography performed 14 days after the procedure showed complete occlusion of the fistula with a small residual pseudoaneurysm. One year later, the pseudoaneurysm had decreased in size. Repeated transient decrease and stagnancy of blood flow at the fistula during the balloon procedure may have played an important role in the thrombosis in this patient.

Stent-graft placement in a traumatic internal carotid-internal jugular fistula and pseudoaneurysm

Traumatic arteriovenous fistulas following carotid artery injuries are rare. Treatment of carotid artery-to-jugular vein fistula requires direct closure of the fistula or occlusion of the carotid artery above and below the level of the fistula, by a surgical or endovascular approach. A 32-year-old man presented with a right-sided pulsatile neck swelling 2 days following a stab wound. Neck computed tomography demonstrated a vascular mass protruding into the anterior neck. Digital subtraction arteriography demonstrated a bilobular large internal carotid artery pseudoaneurysm just distal to its bifurcation. There was simultaneous opacification of a dilated left internal jugular vein indicating a high-flow internal carotid-internal jugular fistula. A balloon-expandable stent-graft was delivered and successfully positioned across the fistula. The arteriovenous fistula and pseudoaneurysm completely disappeared and the right internal carotid artery was well preserved. The stent-graft is a promising technology to obliterate fistulae and preserve the parent artery with relative safety.

Arteriovenous fistula-associated high-output cardiac failure: a review of mechanisms

High-output cardiac failure can be a rare complication of high-output arterioveous fistula. The authors present a case in which a hemodialysis patient with a high-flow arteriovenous fistula has cardiac failure that improves with fistula closure. The hemodynamic effects of a fistula are reviewed, and the hemodialysis literature regarding high-output cardiac failure is summarized. To gain insight into the problem of high-output cardiac failure, research efforts should focus on the prospective monitoring of high-access flows.

Steal Syndrome of the Hemodialysis Vascular Access: Diagnosis and Treatment

Steal syndrome is an uncommon but serious condition of arterial insufficiency distal to a permanent hemodialysis fistula. The management of the condition is a great challenge to the surgeon because of the conflicting goals of preserving the fistula and treat the ischemia. In this review the purpose was to analyze the clinical problem and treatment possibilities. Medline and Embase databases were searched for studies relevant to diagnosis and management of steal syndrome of the hemodialysis vascular access. The diagnosis of steal syndrome is largely based on clinical features and non-invasive studies. In same cases angiography may be necessary to find out the real causes of the steal syndrome. The cause is usually high fistula flow but other causes as steal phenomenon, inflow, outflow or anastomotic stenosis have to be considered and even combination of causes. The main treatment options are some form of flow reducing procedure or the distal revascularization interval ligation method. In some cases simple distal arterial ligation is the method of choice. Furthermore, in some patients a stenosis has to be treated as the first treatment option. For an appropriate treatment of a steal syndrome a careful analysis of the cause is important.

Spontaneous Carotid-Cavernous Fistula in a Patient With Ehlers-Danlos Syndrome Type IV-Case Report-

A 30-year-old female complained of sudden onset of severe proptosis, chemosis, diplopia, and bruit. Right carotid angiography showed a high-flow direct carotid-cavernous fistula (CCF) draining into the engorged superior ophthalmic vein, inferior petrosal sinus, and pterygoid plexus. The patient experienced retroperitoneal bleeding from a ruptured right renal artery after undergoing cerebral angiography. We suspected Ehlers-Danlos syndrome (EDS) type IV, which was confirmed by showing cultured fibroblasts failed to secrete procollagen type III. Endovascular surgery cannot be considered the treatment method of choice in view of the fragility of the arteries and veins in patients with EDS type IV. We treated our patient with extracranial internal carotid artery ligation. Currently, there is no ideal treatment for CCF in patients with EDS type IV. Since CCF is rarely life-threatening, the investigative approach and course of treatment must consider the associated vascular fragility.

Management of a Direct Carotid Cavernous Fistula Caused by Rupture of a Cavernous Aneurysm Previously Embolized with Coils

The development of a high-flow carotid-cavernous fistula from the rupture of a large cavernous aneurysm successfully embolized by coils is rare. A 50-year-old male patient developed a high-flow carotid-cavernous fistula 48 hours after successful coiling of a large left cavernous aneurysm, presumably due to rupture of a focal dissection at or close to the neck of the aneurysm. He initially responded to daily selfcompression of the left common carotid artery, but the fistula recurred. After failing to approach the fistula site via transvenous route, balloon trapping of the internal carotid artery was planned. Prior to its placement for functional occlusion test, the detachable balloon slipped into the fistula site and occluded it. It was thereafter detached in this position. The sequence of events, a large cavernous aneurysm spontaneous ruptured after coiling, suggested dissecting process or disease.We address in the report the complexity of the endovascular management of this rare association.

Presacral Arteriovenous Fistula: Case Report

We describe a case of arteriovenous fistula in front of the sacrum. Drainage induced epidural venous dilation in the sacral spinal canal. The fistula was embolized endoarterially with n-butyl-2-cyanoacrylate via its iliac arterial feeders. In follow-up digital subtraction angiography 1 month later, the fistula was found to be totally closed. The patient was followed up clinically for 2.5 years. She has remained symptom-free. A previously healthy 43-year-old woman presented with severe gluteal and perineal pain and a local sensation of hyperesthesia. The primary computed tomographic scan of the lumbosacral spine was normal, and emergency laparoscopy showed no signs of any pathological lesions. Magnetic resonance imaging discovered an unidentified mass in the sacral spinal canal, and the patient was hospitalized for neurosurgery. However, surgery on this mass had to be discontinued because of profuse bleeding, and the patient was referred for angiography. Diagnostic catheter angiography revealed a high-flow arteriovenous fistula anterior to the sacrum, and the mass detected earlier by magnetic resonance imaging seemed to be a dilated epidural vein draining the fistula. The feeders of the fistula originated in both internal iliac arteries, and the fistula was occluded via these arteries in two angiographic sessions. A paraspinal arteriovenous fistula may have venous drainage through the epidural venous plexus, and the ectatic veins may induce radicular symptomology. To the best of our knowledge, a paraspinal fistula at such a presacral location has not been documented previously. An unidentified mass in the sacral spinal canal should be suspected of being a dilated vascular structure. Prompt angiographic examinations with an option for embolization should be performed, and open surgical intervention should be avoided.